Breast masses

Background
Breast masses are broadly classified as benign or malignant. Common causes of a benign breast mass include
fibrocystic disease, fibroadenoma (see the image below), 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. Reassuringly, most breast masses are benign.

Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated

margins typical of a fibroadenoma.

See Breast Lumps in Young Women: Diagnostic Approaches, a Critical Images slideshow, to help identify and
manage palpable breast lumps in young women.
Breast infections are divided into lactational and nonlactational infections. This division is also referred to as
puerperal versus nonpuerperal when the process is not associated with pregnancy. The process may be
confined to the skin overlying the breast, or it may result from an underlying lesion (eg, sebaceous cyst), as
inhidradenitis suppurativa.[1, 2]

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 owing 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 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, 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 ductsa 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, 5] 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.

Epidemiology
Frequency
United States
After skin cancer, breast cancer is the most commonly diagnosed cancer in women. It accounts for
approximately 1 in 4 cancers diagnosed in US women. [6]
Breast infections occur in as many as 10%-33% of lactating women. [7, 8]
Lactational mastitis is seen in approximately 2%-3% of lactating women, [3, 9] and breast abscess may develop in
5%-11% of women with mastitis.[9]

Mortality/Morbidity
Breast mass
Morbidity and mortality depends on etiology.
Approximately 1 in 28 women (3.6%) die of breast cancer. In 2009, approximately 40,170 women were
expected to die from breast cancer, second only to lung cancer.[6]
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. [7]
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. [10, 11]

Race
African American women have a higher incidence of breast cancer before age 40 years and are more likely to
die of breast cancer at every age.
White women have a higher incidence of breast cancer than African American women after age 40 years. [12]
Race does not appear to be a factor in the incidence of developing a breast abscess. [13]

Sex
More than 99% of breast cancers are found in women; 0.7% of breast cancers occur in men. Men with changes
in breast size should undergo diagnostic workup completed as aggressively as in women. [10, 11, 14, 15]

Age
Fibroadenoma, a benign condition, is the most common cause of breast mass in women younger than 35
years.
Women aged 40 years or older account for more than 95% of new breast cancer diagnoses and 97% of breast
cancer deaths.
The median age at breast cancer diagnosis is 61 years.

Breast infections most commonly affect women aged 18-50 years.

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]

History
Breast mass

Palpable mass (typically unilateral)

Family history of breast disease (malignant or benign)
Early menarche (< 12 years) and obstetrical parity (nulliparity)
Late menopause (age >55 years)
Associated symptoms of pain, nipple discharge, and skin changes (eg, dimpling or inflammation,
nipple inversion)
Length of time present, speed of growth

Mastitis

Localized breast erythema, warmth, and pain

May have fever, chills, or rigor
Lactation history including difficulty with breastfeeding, breast engorgement, or chafed nipples

Breast abscess

Localized breast edema, erythema, warmth, and pain

Any history of prior breast infection
Associated symptoms of fever, nausea, vomiting, and spontaneous drainage from the mass or nipple
Lactation history (consider if weaning or returning to work)
If not lactating, consider diabetes (polyuria, polydipsia, frequent infections, weight change)

Physical
Perform a thorough breast examination in any patient presenting with a breast complaint and in any older
woman presenting with unexplained weight loss, anorexia, or bone pain.

Breast mass

Firm mass of variable shape and size

Fifty percent of masses found in the upper outer quadrant of the breast
May have associated pain with palpation (most are painless)
Nipple discharge, inversion, changes, or asymmetry
Skin retraction or tethering
Axillary lymphadenopathy
Inflammatory changes of the skin (ie, peau d'orange)
Pay special attention to associated upper-extremity neurologic motor or sensory abnormalities, as
these may herald invasion of the brachial plexusan indication for emergent radiation therapy

Mastitis

Localized breast erythema, warmth, induration, swelling, and tenderness

May have associated fever

Breast abscess

Localized breast erythema, warmth, induration, edema, and tenderness

Most frequently areolar or periareolar (may also be peripheral)
Fluctuance, although swelling may limit ability to palpate a mass
May have associated fever or axillary lymphadenopathy
Nipple discharge or inversion

Causes

Malignant
Risk factors include the following:

Female sex
Age older than 40 years
Family history of a first-degree relative with breast cancer
Menarche before age 12 years
Menopause after age 55 years
Nulliparity
First pregnancy after age 30 years
Therapeutic radiation over chest before age 30 years
Hormone replacement therapy
BRCA1 and BRCA2 mutations (responsible for approximately 5% of all breast cancers; inherited in an
autosomal dominant fashion; women with mutations in either of these genes have a lifetime risk of breast
cancer of 60%-85% and a lifetime risk of ovarian cancer of 15%-40% [16] )

Benign
Fibrocystic changes
Lobules of the breast may dilate and form cysts of varying sizes, due to hormonal changes in the menstrual
cycle. Cysts are found in about 1 in 3 women aged 35-50 years. [6] Rupturing of the cysts can cause scarring and
inflammation that leads to fibrotic changes, which feel rubbery, firm, or hard.
Hyperplasia
Hyperplasia is caused by an overgrowth of cells that line the ducts or lobules. About 1 in 4 women have mild or
usual hyperplasia.[6] About 1 in 25 women have atypical hyperplasia (associated with an increased risk of
malignancy).[6]
Adenosis
An increase in the number of glands.
Fibroadenoma[3]
Fibroadenoma is the most common cause of breast mass in women younger than 25 years. These arise from
the terminal duct lobular unit and appear clinically as singular, firm, rubbery, smooth, mobile, painless masses
ranging in size from 1-5 cm. They may grow to a large size, thereby affecting the contours of the overlying skin
and overall shape of the breast. Ultrasonography reveals a well-defined hypoechoic homogeneous mass 1-20
cm in diameter.[7] Fibroadenomas appear as multiple masses in 10%-15% of patients. [7]
Phyllodes tumor[3]
Phyllodes tumor is also known as cystosarcoma phyllodes or giant fibroadenoma. Although generally benign, a
malignant variant occurs in 10% of cases. Incidence is highest among women aged 40-60 years. Most common
presentation is that of a large (average 5 cm), solitary, firm, breast nodule.
Papillary adenoma of the nipple[3]
Papillary adenoma is also known as erosive adenomatosis of the nipple, adenoma of the nipple, florid
papillomatosis of the nipple, and subareolar duct papillomatosis of the nipple. This is believed to arise from
terminal lactiferous ducts. Incidence is highest among women aged 40-50 years. It commonly presents with
unilateral serous or bloody nipple discharge that increases before menses.
Breast abscess
Puerperal breast abscesses most often contain S aureus and streptococcal species. Methicillin-resistant S
aureus (MRSA) has become increasingly common.[13]Nonpuerperal abscesses typically contain mixed flora (S
aureus, streptococcal species) and anaerobes. Diabetes is strongly associated with incidence and clinical

outcomes of breast abscesses in nonlactating women. One study demonstrated a 72% prevalence of diabetes
in women with nonpuerperal abscesses.[17] Cigarette smoking is a debated risk factor.[18, 13]
Mastitis
Mastitis occurs in up to 10%-33% of lactating women, with its highest incidence within 6 weeks postpartum or
while weaning breast feeding.[9, 19, 20, 20] Periductal mastitis comprises 3%-4% of all benign lesions of the breast.
[3]
S aureus is the most common cause. Streptococci, enterococci, S
epidermidis, Peptostreptococcusspecies, Prevotella species, and Escherichia coli are less common causes.
True fungal mastitis is rare and should prompt evaluation for coexisting diabetes mellitus. In infants, infections
with Shigella, E coli, and Klebsiella species have been reported.[11]

Differential Diagnoses

Abscess
Benign breast mass
Breast Cancer
Cellulitis
Mastitis

Laboratory Studies

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

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. [21, 22] For more information,
see Breast Cancer, Ultrasonography.
Various types of breast masses are shown in the images below.

Ultrasonogram demonstrates a hypoechoic mass with smooth, partially

lobulated margins typical of a 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.

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%. [23,
24]
Approximately 5%-10% of screening examinations are interpreted as abnormal, but 90% of women
with abnormal results do not have breast cancer.[23, 24] For more information, see Breast, Benign
Calcifications,Breast, Fibroadenoma, Breast, Nipple Discharge Evaluation, and Breast Cancer,
Mammography.
Various breast masses are shown in the mammograms below.

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.

thinner than those of lucent-centered calcifications.

calcifications (arrows) is a degenerating fibroadenoma.

Eggshell or rim calcifications (arrows) have walls

This mass with associated large, coarse

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.[25, 26, 27]

Catheter drainage for larger abscesses is sometimes considered, although one study reported that
serial needle aspiration and irrigation with sterile saline, when combined with intracavitary antibiotic
injection, had a 91% cure rate.[28]
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. [29] Surgical resection may be required
for infected or obstructed lactiferous ducts. [28]

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

Treat with antistaphylococcal antibiotics, warm or cold compresses, and continued emptying of the
breast by breastfeeding or breast pumping.[1]
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.[30]

Breast abscess

Identify the problem with a detailed history and physical examination and breast ultrasonography and
provide adequate analgesia, antibiotic therapy, and prompt surgical consultation.

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.[5] Similarly, refer patients with breast abscesses for surveillance of
complications and possible recurrent breast abscesses.

Medication Summary

The goal of therapy is to eradicate the infection and minimize complications.

Antibiotics

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

Nafcillin (Unipen)

View full drug information

DOC for puerperal breast abscess. Treats infections caused by penicillinase-producing staphylococci.
Used to initiate therapy when a penicillin Gresistant staphylococcal infection is suspected.
Because of occasional occurrence of thrombophlebitis associated with parenteral route (particularly in
elderly persons), administer parenterally only for a short term (24-48 h) and change to PO if clinically
possible.

View full drug information

Vancomycin (Vancocin, Vancoled, Lymphocin)

DOC for patients with puerperal breast abscess who are penicillin allergic. Potent antibiotic directed
against gram-positive organisms and active against enterococcal species. Useful in treatment of
septicemia and skin structure infections. Indicated for patients who cannot receive, or have failed to
respond to, penicillins and cephalosporins or who have infections with resistant staphylococci.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after the third dose
drawn 0.5 h before next dosing. Use CrCl to adjust dose in renal impairment, prn.

View full drug information

Clindamycin (Cleocin)

DOC for nonpuerperal breast abscess. An alternate DOC for patients with mastitis who are penicillin
allergic.
A lincosamide useful as treatment against serious skin and soft tissue infections caused by most
staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci.
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where
it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.

View full drug information

Ampicillin-sulbactam sodium (Unasyn)

Alternative DOC for nonpuerperal breast abscess. Drug combination that utilizes a beta-lactamase
inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

Dicloxacillin (Dycill, Dynapen)

View full drug information

DOC for mastitis. Bactericidal antibiotic that inhibits cell wall synthesis. Used to treat infections caused
by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal
infection is suspected.

View full drug information

Oxacillin (Bactocill, Prostaphlin)

Bactericidal antibiotic that inhibits cell wall synthesis. Used in the treatment of infections caused by
penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection
is suspected.

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, drainage, and fistulectomy in the operating room. The wound can be left to
close by secondary intention or with simple sutures over a drain.

Further Outpatient Care

Breast mass
Timely follow-up with primary physician and surgeon, mammography, and possible needle biopsy of the mass
are indicated.

Mastitis
For detailed therapy, see Mastitis Empiric Therapy and Mastitis Organism-Specific Therapy
In general, treat with antibiotic therapy for 10-14 days, warm or cold compresses, and continued breast
emptying by breastfeeding or breast pumping every 2 hours or when engorged is indicated. In breastfeeding
mothers, use beta-lactamase stable penicillin (since breastfeeding). Other choices are dicloxacillin 500 mg
orally 4 times daily or cephalexin 500 mg orally 4 times daily for 10-14 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.[31]

Screening tests
Multiple guidelines are available pertaining to breast cancer screening. The 3 most cited include those by the
American College of Physicians (2008), the American Cancer Society (2009), and the United State Preventive
Services Task Force (2009).
The guidelines share the following:

No clear recommendations for breast self-examination

No clear recommendation for clinical breast examination
Mammography from ages 50-74 either yearly (ACS, ACP) [6] or every 2 years (USPSTF) [32]
For women aged 40-49 years, the ACP guidelines (2008) advocate an individualized approach in which
clinicians should base decisions on the potential benefits and harms of mammography, the woman's
preferences, and her breast cancer risk profile.
Current evidence is insufficient to assess the additional benefits and harms of screening mammography in
women aged 75 years or older. Women older than 75 years should have an in-depth discussion with their
physician to consider the risks and benefits of screening mammography, and decisions to start, stop, or
continue screening mammography should be individualized.

Inpatient & 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.
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.

Complications
Potential complications are as follows:

Breast mass - Chronic pain, scarring or disfigurement, metastases, postsurgical complications (eg,
ipsilateral lymphedema), and death
Mastitis - Breast abscess formation in less than 10% of cases
Breast abscess - Recurrent infection, scarring, loss of breast size, and noticeable breast asymmetry
Chronic breast abscess - Mammary duct fistulization, resection of the nipple-areolar complex [5]

Prognosis
Breast mass: Prognosis varies from excellent in patients with a fibroadenoma to poor in those with
inflammatory breast cancer. Influencing factors include tumor size, histology, nodal involvement, distant
metastases, and comorbid conditions.
Breast abscess: Unfortunately, the recurrence rate of breast abscess is high (39%-50% when treated with
standard incision and drainage). Studies of patients with fistulectomy show lower recurrence rates.
Mastitis: Most patients experience resolution within 2-3 weeks. All patients with symptoms that have not
resolved within 5 weeks should be evaluated for resistant infection or malignancy.

Patient Education
Educate women who are lactating on nipple hygiene because cracking and abrasions of the skin increase risk
of infection.
For excellent patient education resources, visit eMedicineHealth's Women's Health Center and Cancer Center.
Also, see eMedicineHealth's patient education articlesBreast Infection, Breast Lumps and Pain, Breast SelfExam, and Breast Cancer.