Management of the Inflamed Breast V Sun, P Sanghavi, H Mabry, DR Holmes Los Angeles County + University of Southern California Medical Center, Los Angeles, CA History and Physical Revealing Breast inflammation Symptoms & Signs Inflammatory BC (Images 1-5) Duration Several Weeks Image 2 Abscess (Image 6) 1-2 Weeks 1-2 Weeks Fever Absent Present or Absent Present or Absent Pain Present or Absent Present Present Erythema Irregular Margins Smooth Margins Smooth Margins Edema Generalized Localized Localized Fluctuant Mass Image 1 Mastitis (Image 6 – mass) Absent Present or Absent Palpable Mass Absent Absent Present Adenopathy Present Absent Present Present Image 3 Image 4 Inflammatory Breast Cancer (Images 1, 2, 3) showing edema and erythema with irregular borders. Image 5 Image 6 Inflammatory Breast Cancer showing edema, erythema with irregular borders (Images 4 & 5), and skin pitting (peau d’orange) (Image 5). Image 6 shows breast abscess (fluctuant mass) with associated erythema and edema. Non-Fluctuant Send to RadiologyD for same day ultrasound (or perform US) Fluctuant A. Mass seen by ultrasound Solid mass Fluid-containing mass suggestive of Abscess (Image 8) (Image 7) Initiate work up of Breast AbscessA B. Management of Infection Options for Oral Antibiotic Therapy: Bactrim DS BID X 10 days Flagyl 500 TID X 10 days If Allergic to Sulfa: Ciprofloxacin 500 BID X 10 days Fever, chills, pain, erythema with smooth borders, or post-partum? Consider Acute Mastitis Consider Inflammatory Breast Cancer Initiate work up of Inflammatory Breast CancerC and refer to Surgical Oncology Clinic in 1 weekD Common infectious agents: Staphylococcus aureus (most common) Staphylococcus epidermidis Streptococci species Abscess Work up 1. Aspirate with 18G or 14G needle or larger to confirm presence of pus 2. Send sample of pus for Gram stain, culture, and sensitivity studies 3. Initiate antibiotic therapyB 4. Send patient to Radiology for same day ultrasound (or perform Ultrasound) 5. Schedule follow-up with General Surgery Clinic within 1 weekD No mass seen by ultrasound If signs of systemic toxicity are present (Temp >38.5º C, WBC > 15,000/mm3, HR>100, SBP <100mmHg) or if patient is immunocompromised or diabetic, surgical consultation should be obtained for possible admission and parenteral antibiotics: Options for IV Antibiotic Therapy: Nafcillin or Oxacillin 2g IV Q4h Cefazolin 1g IV Q6h Initiate antibiotic therapyB and send to Ob/Gyn Breast Friday Clinic within 1 weekD Erythema with irregular borders, skin pitting, breast edema, or marked axillary adenopathy, but no fever or chills? Consider Inflammatory Breast Cancer Initiate work up of Inflammatory Breast CancerC and send to Surgical Oncology Clinic within 1 weekD If inflammation does not resolve within 3 weeks of initial occurrence, send to Surgical Oncology Clinic within 1 weekD <3 cm diameter by ultrasound >3 cm diameter by ultrasound Aspirate completely with ultrasound guidance. Repeat ultrasound within 1 week. Place pigtail drainage catheter under ultrasound guidance If Abscess persists, re-aspirate completely and repeat ultrasound within 1 week Repeat ultrasound in 2-3 days to ensure adequate drainage. Repeat aspiration or continue catheter drainage if necessary. Abscess and inflammation resolve Abscess and inflammation persist Follow up with General Surgery Clinic within 2-4 weeksD Send to Surgical Oncology of General Surgery Clinic within 1 weekD Send to Surgical Oncology of General Surgery Clinic within 1 weekD References 1. Berna-Serna JD. Percutaneous management of breast abscesses: An experience of 39 cases. Ultrasound in Medicine & Biology. 2004. 30(1):1-6. C. Work-up of Inflammatory Breast Cancer 1. Bilateral Mammograms 2. Ultrasound of inflamed breast and axilla 3. Ultrasound-Guided Biopsy of breast mass 4. Ultrasound-Guided Biopsy of enlarged axillary node 5. 4mm diameter, full thickness punch biopsy of erythematous skin (optional) 6. Refer to Surgical Oncology Clinic within 1 weekD 2. Christensen AF. Ultrasound-guided drainage of breast abscesses: results in 151 patients. British Journal of Radiology. 2005. 78(927):186-188. 3. Cristofanilli M. Update on the management of inflammatory breast cancer. Oncologist. 2003. 8(2):141-148. 4. Eryilmaz R. Management of lactational breast abscesses. The Breast. 2005. 14(5):375-379. 5. Gilbert DN. The Sanford Guide to Antimicrobial Treatment, 2004 (34th Edition). Antimicrobial Therapy, Inc. Vermont. 2004. Image 7 Image 8 Image 7 showing solid mass with irregular borders suggesting cancer. Image 8 showing fluid-containing mass suggesting abscess. 10. Givens ML. Breast disorders: a review for emergency physicians. Journal of Emergency Medicine. 2002. 22(1):59-65. 11. “UCSF, Mount Zion, SFGH, and SFVA Recommended Initial Antimicrobial Therapy in Adult Outpatients,” UCSF and UCSF-Mount Zion Pharmacy and Therapeutics Committees, June 1999.