Minal Amin and John M. Howell
Effective ED evaluation of a breast mass depends on recognition of two major processes: Cancer and infection. Mastitis and breast abscesses usually occur in lactating women, but may also represent inflammatory carcinoma in the elderly (3,6,9). Cancer, on the other hand, may present in a manner similar to that of fulminant mastitis (6,9). Mastalgia, a palpable breast mass, and nipple discharge represent common complaints in patients seeking medical attention (6). Hence, initial evaluation of a breast mass may be difficult, challenging, and highly relevant to ultimate patient outcome.
CLINICAL PRESENTATION
Approximately 80% of breast lesions are benign and present as smooth, movable, and discrete masses with regular margins (Table 134.1). Fibrocystic changes (FCCs) and fibroadenomas (FAs) are the most common and second most common benign breast disorders in women (2,4).
TABLE 134.1
Physical Findings Suggestive of Benign and Malignant Breast Masses
Cancerous lesions are hard with distinct edges that are serrated and irregular. Skin changes range from none to local edema or frank ulceration (3,5,7). Fibrosis may shorten the Cooper ligament and cause skin dimpling, a process also seen in fat necrosis (5,7). Bloody nipple discharge suggests ductal carcinoma (8). More commonly, it may reflect the presence of a solitary benign intraductal papilloma (7). Lymph nodes involved in the spread of breast cancer are initially rubbery and shotty. Ultimately, they harden with progressive infiltration. The axillary ipsilateral node glands are most commonly involved followed by the internal mammary and supraclavicular sites (5,7).
Erythema, edema, tenderness, and induration are late skin changes in the setting of breast cancer, but they are commonly seen in lactation mastitis typically 1 to 3 months postpartum (4,6,7). Chronic, relapsing nonpuerperal infection can develop in the subareolar ducts. This is known as periductal mastitis or duct ectasia and has been linked to diabetes and smoking (5). Fluctuance is the hallmark of a superficial abscess. Fluctuance may not be apparent if deep intramammary and retromammary loculations are present in the breast musculature (Fig. 134.1) (10). A “peau d’orange” appearance characterized by diffuse erythema and edema, mastitis, or abscess in a nonlactating woman should serve as a warning sign of inflammatory cancer (3,6,7,9).
FIGURE 134.1 Breast abscesses. A: Superficial abscess. B: Intramammary abscess. C: Retromammary abscess.
Postmenopausal breast abscesses are commonly subareolar, often presenting with pain and erythema. They are occasionally associated with chronic fistulas from the subareolar ducts to the periarolar skin (5). Expressing pus from the nipple or areola can identify a mammillary fistula. Nipple retraction and inversion are also seen (5). Although rare, recurring subareolar abscess (Zuska disease) is a bacterial infection of the breast that is characterized by a triad of draining cutaneous fistula from the subareolar tissue; a chronic thick, pasty discharge from the nipple; and a history of multiple, recurrent mammary abscesses (4).
Breast bud enlargement occurs in the first 1 to 2 weeks of life in 60% of neonates. These enlarged breast buds may become infected, usually with either Staphylococcus aureus or Escherichia coli. The clinical presentation is either simple cellulitis or abscess (8).
Paget disease of the nipple reflects carcinoma of the mammary ducts underlying the nipple areola complex. It represents 2% to 4% of breast malignancies. Initially, it appears as an eczematoid rash and then progresses to chronic skin inflammation with a surface crust. It can be confused with benign breast disease (5,11).
DIFFERENTIAL DIAGNOSIS
Cancer
One in eight women in the United States develops breast cancer. An estimated 234,580 new cases of breast cancer in women and 2,240 in men will be diagnosed in 2013 (1). It is the leading cause of death in women between the ages of 44 to 50. Yearly, approximately 40,000 women die of breast cancer (1,2). Seventy percent to 80% of women diagnosed with breast cancer will have no family history. Primary risk factors for breast cancer are age greater than 50 and being female (1,2). Risk factors for breast cancer are listed in Table 134.2. Absolute risk is listed in Table 134.3. In women who are younger than 25 years of age, fewer than 5% of breast masses are malignant. The incidence of breast cancer rises significantly during childbearing years. By the age of 70, more than 75% of breast masses are malignant (12). Discussions of breast cancer histopathology and staging are beyond the scope of this chapter and are contained elsewhere (2,7).
TABLE 134.2
Risk Factors and Relative Risk of Breast Cancer
TABLE 134.3
Absolute Risk of Breast Cancer in American Women by Age
Benign Neoplasms
FCCs, formerly called fibrocystic disease, comprise the most frequent benign disorder of the breast (4). They are noncancerous changes in breast tissue. They cause mastalgia, tenderness, and nodules to arise in one or both breasts prior to menses in women between 20 and 50 years of age (4). Fibrocystic breast changes are classified proliferative or nonproliferative (up to 70% of biopsies) (4). Proliferative changes are associated with ductal hyperplasia and must be followed longitudinally as there is a four- to fivefold increase in breast cancer in these women (2).
FAs are the second most common benign neoplasms of the breast (2,4). They occur most commonly in younger women between the ages of 15 and 35 and are considered a disease of early reproductive life. They are nontender, well defined, spherical, firm, and highly mobile. In most cases, FAs are managed conservatively as they do not increase the risk of breast cancer. Women who are older have complex FAsor a family history of breast cancer have a higher incidence of cancer (4).
Lipomas are superficial and occur in any quadrant of the breast. They are benign tumors composed of mature fat cells and are well defined, smooth, lobulated, and nontender. It may be clinically difficult to distinguish lipomas from other conditions, thus causing diagnostic and therapeutic challenges (4).
Mondor Disease
Mondor disease is thrombosis of the superior epigastric, thoracoepigastric, or lateral thoracic veins as they traverse the breast. It is characterized by the sudden appearance of a red tender and palpable cord. The cord subsequently becomes a fibrous band associated with tension and skin retraction. Although Mondor disease is self-limited and usually diagnosed with ease (13,14), emergency physicians must be aware of its existence to properly diagnose it and to rule out the presence of systemic disorders, especially breast cancer (13,14).
Idiopathic Granulomatous Mastitis
Idiopathic granulomatous mastitis (IGM) is a rare inflammatory breast disease of unknown etiology. The clinical presentation can mimic an abscess, infectious mastitis, or mammary carcinoma and can be misdiagnosed as cancer. IGM is associated with women who are parous and have a history of oral contraceptive use. Glucocorticoid therapy, resection, and methotrexate are treatment options (15,16). The recurrence rate has been reported as 5% to 50% in the literature (17).
Mastitis and Abscess
Infectious complications may be seen in up to 10% of lactating women (18). Lactation mastitis occurs in 2% to 3% of women and breast abscess between 5% to 11% of women with mastitis (19). A postpartum breast abscess is caused by normal skin pathogens that invade through cracks in the nipple (2,4,10). Staphylococci are the most common causative agents (2,4). Streptococci are cultured less often (8). Preventive measures include nipple hygiene (cleaning), hand washing, cleansing of the infant’s skin, and early recognition (8).
Postmenopausal breast abscesses are distinct from puerperal forms in cause and presentation. Approximately 90% are subareolar. They often arise from mixed infections that include aerobic and anaerobic flora (5). They are associated with ductal ectasia, a chronic inflammation of major ducts below the nipple and areola. Recurrence rates after simple incision and drainage exceed 39% (3). Mammillary fistulas occasionally form between the areola and infected lactating glands (8,9).
Fat necrosis may present as a tender lump in the breast, typically as a result of trauma in 50% of cases (2,3,4). It is a benign, nonsupportive inflammatory process of the adipose tissue. The mass usually does not enlarge but may be ill-defined, spiculated, and associated with skin retraction. It is a mimic of breast cancer (2,3,4).
ED EVALUATION
Evaluation in the emergency department (ED) hinges upon the information gathered during the history and physical examination. As noted previously, many features including the size, location, tenderness, skin changes, and rapidity of onset help in narrowing the differential. The important distinction is cancer versus infection. Patients with a mass suspicious for cancer usually require no further ED evaluation but need expeditious outpatient referral. Patients with signs or symptoms of metastatic cancer should have further ED evaluation including laboratory and imaging studies to search for complications and the extent of spread. Ultrasound may be helpful in diagnosing a breast abscess if the clinician is uncertain. Sonographic evidence suggestive of a breast abscess includes a hypoechoic rim and adjacent interstitial fluid (20,22).
KEY TESTING
• Consider ultrasound if abscess is suspected
ED MANAGEMENT
Simple mastitis in the lactating woman, without abscess formation, is treated with antimicrobials that are effective against staphylococci and streptococci (2,5). Cephalexin (250 to 500 mg four times a day), dicloxacillin (250 to 500 mg four times a day), or erythromycin (250 to 500 mg four times a day) in penicillin-allergic patients is appropriate. Breastfeeding should be encouraged with manual pumping, if needed, along with local heat and empiric antibiotic therapy (2,4,5). Simple nonlactating breast infections should be treated with amoxicillin–clavulanic acid at 875 mg twice a day (3,5).
Superficial abscesses can be treated in the ED. Ultrasound-guided needle aspiration is emerging as a treatment of choice for most breast abscesses. It causes less scarring and does not require general anesthesia. Repeated aspiration and oral antibiotics may be necessary (8,10).
Neonatal breast bud infections should be treated with parenteral antibiotics (e.g., ampicillin 50 mg/kg and cefotaxime 50 mg/kg) after cultures of the blood and urine. Incision and drainage may be necessary and should be performed peripherally to avoid cosmetic complications (21).
CRITICAL INTERVENTIONS
• Refer all patients with a suspicious breast mass for expeditious outpatient evaluation.
• Drain superficial breast abscesses, with ultrasound guidance as needed.
DISPOSITION
Women suspected of having breast cancer should be referred immediately to a consultant who is experienced in the diagnosis and management of breast disorders. Outpatient arrangements for mammography with subspecialist referral should be made for all patients who are not pregnant and at least 20 years old. As there is an appreciable rate of false-negative mammography (3,19), patients should be counseled that a negative study does not invariably mean absence of disease.
Mastitis may be difficult to distinguish clinically from cellulitis, abscesses, or inflammatory cancer. Patients should be closely followed within 24 hours. Mammillary fistulas should be referred to a surgeon for excision and definitive closure (8–11). Postmenopausal abscesses also necessitate surgical consultation due to high recurrence rates after drainage (3,8–10,22).
Patients with suspicious breast masses need not be admitted unless they have advanced disease or complications on presentation, intractable pain, or important psychosocial issues necessitating admission. In general, the initial evaluation of suspicious breast masses is done on an outpatient basis.
Women with mastitis who are toxic-appearing should be admitted and placed on intravenous antibiotics. Women with simple infections that do not improve or that worsen after 24 hours should also be admitted.
Consider transfer or referral when no physician experienced in the management of breast disorders is available. Patients must be stable and have no evidence of septic shock. Antibiotics and pain control should be initiated prior to transfer.
Common Pitfalls
• Inflammatory cancer may present with erythema, edema, and tenderness. Infection in a nonlactating breast and failure of postpartum mastitis to resolve in a timely manner should suggest the possibility of cancer.
• Inadequate drainage of a breast abscess may lead to chronic infection with substantial morbidity and cosmetic deformity.
• Misdiagnosis of a deep breast abscess as mastitis.
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