Predictors of primary breast abscess and recurrence Presenter: Boitumelo Phakathi

Predictors of primary breast
abscess and recurrence
Presenter: Boitumelo Phakathi
Moderator: Dr H Pienaar
Breast abscess
• Inflammatory breast mass that drains a
purulent material either spontaneously or
on incision
• Primary breast abscess: abscess occurs
spontaneously
• Secondary breast abscess:abscess
secondary to causes such as breast
cancer, post-radiation or post-elective
breast procedure
Breast abscess
• Recurrent breast abscess
repeat drainage
same breast quadrant
within 6/12
• Puerperal breast abscess- breast
abscess during pregnancy, during the first
3/12 postpartum without lactation, during
lactation or during the first 3/12 after
cessation of lactation
Breast abscess
• Sub-classification based on the location:
Sub-areolar/ retro-areolar: located in the
sub-areolar area or within 1cm from the
areolar
Non-subareolar: located > 1cm distal to
the nipple/areolar complex
Predictors-primary breast abscess
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Tobacco smoking
Obesity (BMI >30)
African-American population
Diabetes Mellitus
Nipple piercing- esp. for sub-areolar
subtype
Smoking vs illicit substances
…cntd
• Other predictors for recurrent breast
abscess: (Gollapalli et al.)
Age:
for every year increase in age
an 8% increase in the odds of recurrence
Need for surgical treatment:
12 times likelihood of recurrence
Lactational breast abscess
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Infrequent complication of infectious mastitis
Less common than non-lactational breast abscess and hardly recurs
Usually occurs at 3-8 weeks postpartum
Risk factors:
 primiparity
 birth after 41 weeks of gestation
 age >30
 recent mastitis
Prevention- correct positioning & latch on technique, properly fitted
bra, reducing level of stress
Pathogenesis-breast abscess
• Local inflammation &/or infection of
terminal lactiferous ducts
• Smoking:
smoke toxins secreted into ductal secretions
directly damage the lactiferous ducts
smoking suppresses IL-8 production
(promotes neutrophil chemotaxis at the site of
inflammation)
has an indirect effect through hormonal
stimulation of breast secretion
…..cntd
• Lactational breast abscess
Milk stasis- major predisposing factor
Cracked/ fissures in the nipple or areolarportal of entry for pathogens
Reflux from infant’s mouth
Bacteriology- primary breast
abscess
Bacteriology-recurrent breast
abscess
Treatment options
• Percutaneous drainage
– with or without sonar guidance
– with or without a drain
– antibiotics
• Surgical treatment
Percutaneous drainage
• Advantages: described since the early 90’s
Reduced incidence of scarring & sinus formation
Feasibility of outpatient treatment
Continued breastfeeding in lactating women
Reduced cost
Superior cosmetic results
Short healing duration
Percutaneous drainage
• Without sonar guidance:(Schwarz RJ et al)
N=33 patients, treated with needle aspiration
and antibiotics
Results:-18 pts-single aspiration
-9 pts-multiple aspirations
-6pts- required surgical drainage
Overall cure rate-82% by percutaneous
drainage,
Conclusion: a needle aspiration without
ultrasound is an effective treatment for
breast abscess.
Percutaneous drainage-Sonar
guided
• Benefits of Sonar:
diagnosis of breast abscess (esp. deep
seated)
guide the needle placement
recognise multi-loculations and ensure
complete drainage of the collections
assess the adequacy of drainage
…cntd
• Elagili F, et al (2007): sonar-guided
percutaneous drainage
N-31 patients
Results: 15 pts-single aspiration
10pts-multiple aspiration
6pts-required surgical drainage
(had multiloculations irrespective
of abscess volume & size)
Conclusion: needle aspiration with
ultrasound guidance is an effective treatment
for breast abscess irrespective of abscess
volume and size
Argument for percutaneous
drainage
• Possibility of missing an underlying malignancy
• Bradford G et al: rate of malignancies in breast abscess
10 years retrospective study
Histology results:
-60% =acute inflammation
-4.37%=malignancy
-26%=chronic inflammation, fat
necrosis, FB reaction
 Conclusion: rate of associated malignancies with breast
abscess is very low and does not warrant mandatory
surgical drainage
Surgical treatment
• Indications:
 failed percutaneous drainage modalities
 recurrent breast abscess
 abscess > 5cm
• Disadvantages:
 prolonged duration of healing
 Scarring and skin &/or nipple retraction
 discontinuation of breastfeeding due to pain
 Need of general anaesthesia
 Need of hospital stay
Conclusion
• Breast abscess is a common benign breast
pathology
• Non-lactational breast abscess is more common
than lactational breast abscess
• Smoking is a significant risk factor for both
primary & recurrent breast abscess
• S.aureus- primary breast abscess
• Recurrent breast abscess & smokers:mixed
bacterial infection & anaerobes
….cntd
• Sonar guided percutaneous drainage should be
the first line of therapy with antibiotics
• Surgical drainage- failed percutaneous drainage
modalities
• Very low incidence of malignancies associated
with breast abscess
• Failure of resolution of an induration following
treatment warrants a biopsy
References
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Bharat A,et al.World J.Surg (2009) 33:2582-2586
Gollapali V,et al.J Am Coll Surg(2010) 04:41-48
Eryilmaz R,et al.The Breast(2005) 14:375-379
Berna-Serna,et al.Ultrasound in Medicine &
Biology(2004)30:issue1,pg 1-6
Schwarz RJ,et al.J Am Surg(2001)182.Iss.2:pg117-119
Chin-Yau Chen,et al.J Am Coll Surg(2010) 210.Iss.2
pg148-154
Martin J, et al.J Midwifery & Women’s Health.(2009)54,
Iss.2 pg150-151
Elder E, et al.World J.Surg(2010) 34:2257-2258
Elagili F,et al.Asian J of Surg(2007) 30. Iss.1, pg40-44
Bradford G et a/. J Am Surg(2006)192.Iss.6.pg 869-872
Thank you!
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