Fw: Surgical Management of Inflammatory Breast Lesions

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From: ilena rose <ilena@...>

Sent: Thursday, February 22, 2001 2:08 PM

Subject: Surgical Management of Inflammatory Breast Lesions

Inflammatory Breast Lesions And Their Surgical Management

Authors: Edwin B. Buchanan, MD, FACS, A. Bender, MD, Spyros D.

Kominos, ScD, Mercy Hospital of Pittsburgh

<#TOC> Abstract: Inflammatory lesions and infections of the breast are

quite rare. Some exhibit evidence of inflammation in which bacteriologic

studies are negative. In others, organisms can be cultured. Many of these

lesions clinically resemble cancer. [Comp Surg 14(5): 551-556, 1995. © 1995

SCP Communications, Inc.]

<#TOC> Introduction

Breast lesions presenting with inflammation may be classified into 2

types: the aseptic or inflammatory and the septic or bacterial. They may

also be separated in regard to breast site: peripheral or central (within

1cm of the areola). Other commonly used descriptive adjectives are

premenopausal or postmenopausal, and puerperal and nonpuerperal.

Staphylococcus aureus is the most common organism retrieved in septic

patients with inflammation. Although mammography and physical examination

are mandatory, they are often of limited benefit in differentiating these

lesions >from cancer. They present as tender or inflamed masses, often

with overlying skin redness. Culture, however, fails to grow any bacteria.

Breast implants are a fairly common cause of breast pain and inflammation.

Silicone gel implants in a silicone bag covered with a polyurethane

coating were popular until recently, when legal action necessitated the

use of only saline implants enclosed in a silicone bag with no polyurethane

coating. Implants may be placed either superficial or deep to the pectoral

muscle, and surgical approaches may be either inframammary, periareolar, or

transaxillary.[1] " Silicone mastitis " is an inflammation caused by

silicone breast implants. Leakage through bag prostheses has been

reported,[2] although the actual incidence is unknown. A fibrous reaction

around implants can cause enough pain to warrant their removal. One hazard

of these prostheses is the subsequent difficulty in detecting cancer by

either physical examination or mammography.

The direct injection of silicone or paraffin to achieve breast enhancement

has been used in the past but is now considered to be medically improper

and unsafe.[3] Indeed, the procedure is inadvisable as it causes a

painful reaction, often leading to hard masses, ulceration, or sinus

tracts. It is now rarely performed, except in poorer countries where its

lower cost is a major factor. Mastectomy may be necessary to treat this

chemical mastitis, and excisional biopsy is sometimes needed to rule out

coexisting cancer.

Hematoma and fat necrosis may be seen following significant trauma. This

is a normal pathologic reaction in breast tissue shortly after surgery. In

taking a history, it is important to note the degree of trauma and the

resulting ecchymosis in the corresponding area. The hematoma may calcify,

reabsorb, or later result in fat necrosis. The 2 lesions may be seen

independently of each other, but they usually occur sequentially. If there

is a well-documented history of trauma, the lesion may be needle-biopsied

for diagnosis. If doubt remains, then excisional biopsy is advisable. Fat

necrosis is significant for mimicking carcinoma in the form of a mass with

overlying skin retraction.[4] Benign lesions usually do not require

treatment, because the lumps typically resolve completely.

Inflammatory cancer constitutes 1% to 2% of all breast cancers. It is

characterized by skin erythema and edema, usually an underlying lump, and

invariably, axillary adenopathy. Skin redness and local heat are due to

the hypervascularity accompanying the rapid growth of the underlying

cancer. Diagnosis is confirmed by skin biopsy showing subdermal lymphatic

invasion of tumor cells (in most cases) and typically by needle rather

than incisional biopsy of the underlying breast cancer. As soon as the

diagnosis is established, patients should be referred for chemotherapy.

The mammogram is nondiagnostic and can fail to show an underlying breast

lesion. The thickened pink skin is better visualized directly rather than

by x-ray.

Duct ectasia or plasma cell mastitis is an inflammatory lesion that

possibly accounts for 1% of all operative breast lesions. It is always

central and usually occurs in older women. It is initiated by an

intraductal secretion of fatty acids with dilatation and rupture of the

major ducts.[2] The resulting chemical mastitis involves an infiltration

of plasma cells and later fibrosis with shortening of the major ducts.[1]

The toothpaste-like material that is sometimes seen oozing from these

ducts gives rise to the term " comedomastitis. " The central mass with

nipple retraction may be confused with carcinoma. The proper treatment is

excision of any retroareolar mass for diagnostic purposes, because needle

biopsy may be inconclusive.

Mondor's disease is a superficial thrombophlebitis of the skin of the

breast, usually occurring spontaneously in the upper outer quadrant. The

condition often mimics the appearance of cancer. At the onset, there is a

tender skin erythema, followed in a week or two by linear grooving, skin

retraction, and fibrous band formation.[4] This diagnosis should be

suspected in a patient with a tender, superficial, reddened lesion with no

underlying lump and a negative mammogram. A similar vein thrombosis may

result from trauma or local breast surgery. In these cases a cord-like

band may extend from the breast down as far as the pubis in the form of a

superficial, hyalinized thrombophlebitis. No treatment is required because

these lesions resolve spontaneously, usually within 2 months. Resolution

may be speeded by surgical interruption of this cord.

Granulomatous mastitis is a very rare lesion somewhat similar to duct

ectasia except that it is always peripheral and confined to the breast

lobule.[2] Microscopically, it is a sterile abscess with central necrosis

and surrounding granulation tissue and giant cells. There is no dilatation

of the excretory ducts and no lipid material. These small masses should be

surgically excised or needle-biopsied to confirm the diagnosis.

Septic lesions are those in which specific bacteria can be isolated. The

intact skin of the breast represents a defense against pathogens. However,

the nipple-areolar complex is more porous and does not form as effective a

barrier as skin. Any skin disruption may allow bacteria into the

underlying breast tissue as seen with surgery and ulcerating breast cancer.

Some infections such as periareolar abscess arise from within the breast.

Others are bloodborne and represent a manifestation of systemic disease.

The most common organism in most types of mastitis is S. aureus. Some rare

abscesses may occur without a known portal of entry.

Postoperative infections may complicate breast resection, insertion of

implants, and simple mastectomy. They all constitute " clean " surgery, and

the sepsis rate is usually under 3%. Mastectomy with removal of the

axillary contents probably involves a slightly higher rate, as the axilla

is not considered totally clean. Prophylactic antibiotics need not be used

at surgery. It is difficult to ascertain accurate postoperative sepsis

rates because much of this type of surgery and postsurgical care is done

on an outpatient basis. Infected wounds should be cultured routinely,

although they invariably result >from a hematoma that becomes secondarily

infected with S. aureus. Treatment consists of adequate drainage and

appropriate antibiotics.

In a 1982 Mayo Clinic report on infections associated with breast implants,

S. aureus was found in 21 of 29 infections, and Staphylococcus epidermidis

was recovered in 4.[4] The proper approach to breasts containing infected

implants is a preliminary trial of appropriate antibiotics and later,

removal of the implant if infection has not been controlled. No implant

should be reinserted less than 3 months after its removal for infection.

In the last 10 years, toxic shock syndrome (or more accurately,

necrotizing fasciitis) has also been reported following insertion of

breast prostheses. This infection occurs within the first week of surgery,

and it is imperative that these implants be removed immediately and that

the wounds be thoroughly irrigated. S. aureus produces the exoprotein

responsible for this condition.

Infected sebaceous cysts occur in the breast skin as in other areas of the

body. These are peripheral lesions occurring at any age and are rarely

confused with cancer. Treatment consists of incision and drainage of the

fluctuant abscess and removal of the sac and its contents. The organism

involved is usually S. aureus.

Ulcerating breast cancer always involves bacterial infection. The

underlying cancer invades and destroys the skin barrier. The infection is

typically caused by a mixed flora, with S. aureus predominating. Other

organisms include additional Staphylococcus species, diphtheroids,

streptococci, and enterococci. Whenever a patient with this lesion

undergoes a mastectomy, broad-spectrum antimicrobials should be initiated

following preoperative wound culture.

Periareolar abscess is reported to occur 10 times more frequently than

puerperal abscess. The incidence is probably under-reported because of

poor surgical results, reflected in high recurrence rates. General

surgeons with diversified practices are not likely to encounter more than 2

patients with such a lesion in their lifetimes. These lesions occur most

commonly in premenopausal women. As in duct ectasia, there is nipple

retraction in over half of these cases. However, the 2 lesions differ in

their gross clinical appearance. Duct ectasia usually presents as a

central mass or with noticeable thickening directly beneath the nipple. It

may not be tender in its late stage, and there is no evidence of acute

infection. The periareolar abscess is eccentric, always in or very near

the areola, and does not involve the nipple. There also is evidence of a

pustule and a grossly infected sinus tract in patients with periareolar

abscess.

Most pathologists now believe periareolar abscess to be a bacterial form of

duct ectasia. The basic pathologic change begins with squamous metaplasia

of the lining of 1 or more of the major nipple ducts, with obstruction of

the duct by keratin plugs.[5] The ducts rupture, followed by bacterial

invasion. Suppuration persists until the keratin-producing squamous

epithelium is totally removed. This abscess either ruptures spontaneously

or is surgically incised, and a persistent mamillary fistula is formed

with recurrent abscess formation or purulent drainage.[6]

In the early 1950s it was apparent to American breast surgeons that

excision of the fistula and the major duct system was essential for cure.

This operation was described by Hadfield[7] in 1960. Apparently these

recommendations for excision were ignored by most surgeons; a 10-year

study by Scholefield and colleagues[8] published in 1987 revealed that 75%

of patients with areolar abscess required further surgery for recurrences.

In another 10-year review in 1985, s and colleagues[9] showed that 28

of 34 patients suffered recurrences, and some patients had as many as 6

recurrences after the original surgery. s and coworkers recommended

the prophylactic use of bromocriptine to lower prolactin levels; this

improved their results to only 2 recurrences among 22 patients.

Aerobic cultures of these abscesses have long been known to yield uncommon

strains of staphylococci and streptococci and, more recently, Proteus

morganii. In 1985 Pearson[10] first reported the presence of anaerobes,

which are now found in a majority of cases. and colleagues[11]

showed that the anaerobic peptostreptococci represent the most common

organisms (including aerobes) recovered from periariolar abscesses.

Proper treatment of this lesion requires removal of the mamillary fistula

and the entire major ductal system. Penicillinase-resistant antimicrobials

and metronidazole for anaerobic organisms are strongly advised. This

procedure may have to be repeated but ultimately results in cure. If

recurrence appears in a premenopausal woman after a first surgical

excision, the prophylactic use of bromocriptine is recommended with

subsequent surgery.

Puerperal mastitis and abscess have greatly decreased in incidence

worldwide in the past 20 years. No precise figures are available regarding

occurrence then or now, and the incidence may depend on reporting

differences or geographic site. Factors influencing this decrease in

incidence include the early use of antibiotics and especially the

improvement in antenatal and postnatal breast care.[12]

Mastitis is now seen in approximately 2.5% of nursing mothers and is

frequently bilateral. Sore, fissured nipples are the usual portal of entry

and the cause of incomplete breast emptying. With breast engorgement and

milk stasis, the ducts become plugged with inspissated materials, forming

a stagnant pool of milk, which is an excellent breeding medium for

endogenous organisms. The best treatment for milk stasis is emptying of

the breast by nursing or hand expression.[12] The leukocyte and bacterial

counts in breast milk are used to differentiate breast inflammation from

infectious mastitis that warrants antimicrobial use.[13] Most

epidemiologists believe that infection is introduced through the baby's

mouth. The pathogen involved is invariably S. aureus, which for many years

has been resistant to penicillin and, more recently, to methicillin.[14]

The drugs of choice prior to culture are the cephalosporins, clindamycin,

and vancomycin. Rare organisms causing puerperal abscess include

Salmonella bredeney[15] and group B Streptococcus.[16]

Approximately 10% of the cases of puerperal mastitis proceed to abscess

formation. These are invariably peripheral, and treatment involves incision

and drainage with breaking up of loculations. Benson[17] recommended

curetting these cavities and loosely suturing the skin and cavity edges

around drains to produce more rapid healing. Needle aspiration may be

attempted but is often ineffective because of multiple loculations.

Benson's method may leave a prominent scar. Lactation ceases spontaneously

in half of women who develop puerperal breast abscess.

Systemic diseases are sometimes manifested by breast infections.

Tuberculous mastitis is the most common. It usually occurs in women in

their 20s and 30s and is seen almost exclusively in Australia.[3,18]

Investigators now believe that tuberculosis always occurs in the breast as

a secondary infection. The condition presents as a solitary tender lump in

the breast, often with axillary node involvement. Bilaterality is seen in

only 3% of cases. Most commonly, the mammographic diagnosis is

" carcinoma. " Mammary tuberculosis is classified into 3 types: nodular,

diffuse, and sclerosing. Fistulas from which the Mycobacterium tuberculi

may be isolated are common. Before appropriate drug therapy was available,

mastectomies were often necessary for control of multiple painful lesions.

Current treatment is culture followed by the appropriate antibiotics,

usually isoniazid, rifampin, and pyrazinamide.

Other systemic infections causing breast lesions are actinomycosis,

syphilis, and typhoid fever. [19] described 2 cases of breast

abscess due to Actinomyces meyeri, an anaerobe that normally inhabits the

mouth and pharynx. Treatment of this painful, fistulating breast lesion

often requires surgical debridement and appropriate antibiotics. Syphilis

infection has been found in the breast, both in the form of a chancre and a

gumma. Among women with typhoid fever, 0.9% have breast involvement. Breast

abscess may be the presenting manifestation of the disease.[15] All of

these previously mentioned lesions respond to appropriate antimicrobials,

but excisional or needle biopsy may be required to differentiate them from

cancer.

Miscellaneous peripheral breast abscesses. Most other abscesses are

endogenous in origin. Only a quarter of all abscesses at any age are

peripheral. In the 3-year series by Petrek[20] of 18 postmenopausal women

with breast abscess, half had adult-onset diabetes. It was noted that they

were frequently without leukocytosis, pain, or accompanying cellulitis.

Total excision rather than drainage was recommended for the smaller

lesions. More recently, Ferrara and colleagues[21] recommended attempt at

needle aspiration as the primary procedure in select cases of focal

abscess.

Patients who are immunocompromised may develop abscesses anywhere,

including the breast. Gallium-67 citrate is used in scintigraphy to detect

a latent breast abscess. One report described a silent Mycobacterium

chelonei infection in a young woman receiving high-dose

corticosteroids.[22] A case of severe recurrent breast abscesses caused by

Corynebacterium minutissimum resulted >from a wound infection following

breast biopsy performed through skin afflicted with erythrasma, a minor

dermatosis.[23] Four drainage procedures were performed before infection

was finally controlled with intravenous vancomycin and oral erythromycin.

Some cases of mastitis are clearly the result of exogenous exposure to

bacteria. Outbreaks of Pseudomonas aeruginosa mastitis have been reported

from inadequate chlorination of pools and hot tubs.[24] A superficial

folliculitis of the breast skin occurs, particularly in the Montgomery

glands. This condition is self-limited and subsides spontaneously within 3

or 4 days. The inadvertent use of steroids may cause rapid spread and

predisposition to invasive disease.[25]

Buchanan and Kominos[26] reported a case of a deep peripheral breast

abscess due to P. aeruginosa in a previously healthy premenopausal woman

in whom no source of infection could be found. The patient was toxic, with

erythema involving the lateral half of the breast. She responded in 2

weeks to incisions and drainage, intravenous tobramycin and ticarcillin,

and daily changes of iodophor packs (Figs. 1 to 3).

< " /SCP/CIS/1995/v14.n05/s932.buchanan/Art-s932.fig1.jpeg " >Fgure 1. (click

here to zoom image) Lateral view of right breast, 9 days after drainage of

pseudomonal abscess.

< " /SCP/CIS/1995/v14.n05/s932.buchanan/Art-s932.fig2.jpeg " >Fgure 2. (click

here to zoom image) Frontal view of same breast as in Figure 1.

< " /SCP/CIS/1995/v14.n05/s932.buchanan/Art-s932.fig3.jpeg " >Fgure 3. (click

here to zoom image) Photomicrograph of breast biopsy of pseudomonal

abscess.

A different case of peripheral abscess involved a healthy 46-year-old woman

who presented with a 3cm pink area in the periphery of the breast. Later, a

small underlying lump developed that could not be aspirated. A breast

resection (Fig. 4) was done under local anesthesia for an abscess that

grew pure ella morganii (formerly Proteus morganii). The wound

healed primarily, and the pathology report demonstrated chronic and acute

mastitis with abscess and fibrosis (believed to be at least 1 month old).

The patient subsequently remembered that 5 weeks prior to the appearance

of the lump, she had taken a sample of amphetamines for 10 days that she

had obtained >from a friend who had developed a mouth abscess after taking

the same contaminated pills.

< " /SCP/CIS/1995/v14.n05/s932.buchanan/Art-s932.fig4.jpeg " >Fgure 4. (click

here to zoom image) Photomicrograph of ella morganii-infected breast

abscess.

Garrido and associates[27] reported the first P. morganii isolate from a

nipple discharge from a patient with a breast infection. However, S.

aureus had been recovered in pure culture for the previous 5 years.

<#TOC> Discussion

The surgeon is usually focused primarily on the diagnosis and treatment of

common breast conditions such as cancer, benign tumors, and cystic

disease. The inflammatory lesions described here are rarely encountered.

The following are general recommendations for management of these rare

lesions:

* Obtain anaerobic as well as aerobic cultures on all breast abscesses.

Postoperative infections require only aerobic cultures. * Surgical

treatment of periareolar lesions still remains inadequate, and

recurrences are common. Removal of the nipple and areola will always

provide a cure, but this is often cosmetically unacceptable. * The

peripheral abscess may have a variety of different physical findings

depending on the organism and the status of the patient's immune system.

Puerperal abscess due to S. aureus presents as an obvious fluctuant

abscess. Abscesses due to other organisms may have a deep-seated palpable

lump, with or without fluctuation or overlying skin erythema. *

Peripheral abscesses are more common in immunocompromised individuals,

diabetic patients, and those taking immunosuppressive therapy. They may

also be seen in healthy women in whom the source of infection is

unknown. * Small peripheral abscesses in postmenopausal women are

treated by first attempting needle aspiration. If this is unsuccessful,

then total excision (rather than incision and drainage) should be done.

These wounds heal well, and this approach represents an adequate

lumpectomy if the lesion is found to be cancerous. * Because of the

infrequency of these lesions, mammograms, although sometimes helpful,

are usually of limited aid. False-positive reports of cancer are common.

* Open biopsy is required to differentiate many of these inflammatory

lesions from malignancy if fine-needle aspiration or biopsy is unproductive

or equivocal.*

<#AuthorRef> About the Authors

Dr. Buchanan is Attending Surgeon, Department of Surgery, Dr. Bender is

Resident, General Surgery Program, and Mr. Kominos is Deputy Chief,

Division of Microbiology, Department of Laboratory Medicine at Mercy

Hospital, Pittsburgh, Pa.