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 • • • • • 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 • • • • • 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 • • • • • • • • • • 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!