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.