Background

Breast masses can be broadly classified as benign or malignant. Common causes of a

benign breast mass include fibrocystic disease, fibroadenoma, 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; however, most breast masses are benign.

Breast infection most commonly affects women aged 18-50 years; in this age group, it
can be divided into lactational and nonlactational infections. The process can affect the
skin overlying the breast, where it can be a primary event, or it may occur secondary to a
lesion such as a sebaceous cyst as hidradenitis 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 due 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 the 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 (I&D), 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 ducts—a 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 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.

Frequency

United States

Breast cancer is the most commonly diagnosed cancer in women, after skin cancer,
accounting for approximately 1 in 4 cancers diagnosed in US women.5

Infectious complications occur in as many as 10% of lactating women.6

Lactational mastitis is seen in approximately 2-3% of lactating women,3,7 and breast

abscess may develop in 5-11% of women with mastitis.7

Mortality/Morbidity

Breast mass

• Morbidity and mortality depends on etiology.

• Approximately 1 (3.6%) in 28 women die from breast cancer. In 2009,
approximately 40,170 women were expected to die from breast cancer, second
only to lung cancer.5
• 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.6
• 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.8,9
Race

• African American women have a higher incidence rate before age 40 and are
more likely to die from breast cancer at every age.10
• White women have a higher incidence of breast cancer than African American
women after age 40.

Sex

Greater than 99% of breast cancers are found in women. However, men with changes in
breast size should have diagnostic workup completed as aggressively as women.8,9

Age

Women older than 40 years account for more than 95% of new breast cancer cases and
97% of breast cancer deaths. The median age of diagnosis is 61 years of age.

• 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
• Fibroadenoma is the most common cause of breast mass in women younger than
35 years.

Clinical
History

Breast mass

• Palpable mass, typically only in one breast

• Family history of breast disease, malignant and/or benign
• Menstrual and obstetrical histories are important.
• 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 and chills
• May be lactating and may have recently missed feedings
• May progress to breast abscess

Breast abscess
 • Localized breast edema, erythema, warmth, and pain
• History of previous breast abscess is common.
• Associated symptoms of fever, vomiting, and spontaneous drainage from the mass
or nipple
• May be lactating

Physical

Perform a thorough breast examination for any patient presenting with a breast complaint
and for 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, but most are painless
• Nipple discharge or inversion
• Skin retraction or tethering
• Axillary lymphadenopathy
• Inflammatory changes of the skin (ie, peau d'orange)
• Note, pay special attention to associated upper extremity neurologic motor or
sensory abnormalities, as these may herald invasion of the brachial plexus — an
indication for emergent radiation therapy.

Mastitis

• Localized breast erythema, warmth, induration, and tenderness

• May have associated fever

Breast abscess

• Localized breast erythema, warmth, edema, and tenderness

• Most frequently areolar or periareolar
• Fluctuance
• May have associated fever or axillary lymphadenopathy
• Nipple discharge or inversion

Causes

Malignant

• Breast mass:
o Risk factors for breast cancer include female sex, age older than 40 years,
family history of a first-degree relative with breast cancer, nulliparity,
 menarche before age 12 years, menopause after age 55 years, and late
pregnancy (>30 y of age).
o The BRCA1 and BRCA2 genes are responsible for approximately 5% of all
breast cancers and are 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%.11

Benign

• Fibrocystic changes:
o Spectrum of features includes development of cysts and fibrosis.
o Lobules of the breast may dilate and form cysts of varying sizes, due to
hormonal changes in the menstrual cycle.
o Cysts are found in about 1 in 3 women between 35 and 50 years old.5
o Rupturing of the cysts can cause scarring and inflammation that leads to
fibrotic changes, which feel rubbery, firm, or hard.
• Hyperplasia:
o Hyperplasia is caused by an overgrowth of cells that line the ducts or
lobules.
o About 1 in 4 women have mild or usual hyperplasia.5
o About 1 in 25 women have atypical hyperplasia (associated with an
increased risk of malignancy).5
• Adenosis: This is an increase in the number of glands.
• Fibroadenoma:3
o The most common cause of breast mass in female patients younger than
25 years is fibroadenoma.
o 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.
o They may grow to a large size, thereby affecting the contours of the
overlying skin and overall shape of the breast.
o Ultrasonography reveals a well-defined hypoechoic homogeneous mass 1–
20 cm in diameter.6
o Fibroadenomas appear as multiple masses in 10–15% of patients.6
• Phyllodes tumor:3
o Phyllodes tumor is also known as cystosarcoma phyllodes or giant
fibroadenoma.
o Although generally benign, a malignant variant occurs in 10% of cases.
o Incidence is highest among women in their 40s or 50s.
o Most common presentation is that of a large (average size, 5 cm), solitary,
firm, breast nodule.
• Papillary adenoma of the nipple:3
o 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.
 o This is believed to originate in the terminal lactiferous ducts of the nipple
and subareolar tissue.
o Incidence is highest among women in their 40s.
o It commonly presents with unilateral serous or bloody nipple discharge
that increases before menses.
• Breast abscess:
o Staphylococcus aureus and streptococcal species are the most common
organisms isolated in puerperal breast abscesses. Nonpuerperal abscesses
typically contain mixed flora (S aureus, streptococcal species) and
anaerobes.
o A study by Schafer et al found a significant correlation between cigarette
smoking and subareolar breast abscess.12
• Mastitis:
o Mastitis occurs in 2-3% or more of lactating women, with its highest
incidence in weeks 2-3 postpartum.7,13
o Periductal mastitis comprises 3-4% of all benign lesions of the breast.3
o S aureus is the most common cause. Streptococci, enterococci,
Staphylococcus epidermidis, Peptostreptococcus species, Prevotella
species, and Escherichia coli are less common causes.
o True fungal mastitis is rare and should prompt evaluation for coexisting
diabetes mellitus.
o In infants, infections with Shigella, E coli, and Klebsiella species have
been reported.9