Background: Patients typically do not present in the ED with a breast mass as their chief complaint; however, knowledge of the pertinent anatomy, pathophysiology, and clinical clues is essential. Breast masses can be broadly classified as benign or malignant. Common causes of benign breast masses include fibrocystic disease, fibroadenoma, and abscess. Malignant breast disease encompasses many histologic types that include, but are not limited to, in situ lobular or ductal cancer, intraductal papilloma, infiltrating ductal 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. Pathophysiology: 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. Inflammatory carcinoma is the most aggressive malignant tumor and carries the worst prognosis. The breast is a modified sweat gland with multiple secretory acini that drain into lactiferous ducts. These ducts are grouped into lobules, which are demarcated by Cooper ligaments. Each of the lobule secretory ducts converge to form one ampulla, which traverses the nipple to open at the apex. When the lactiferous duct lining undergoes epidermalization, keratin production can cause plugging of the duct and result in abscess formation. This helps explain the high recurrence rate (an estimated 39-50%) of breast abscesses in patients treated with standard incision and drainage (I&D). 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 is precipitated by milk stasis. Frequency:
Mortality/Morbidity: Race: Premenopausal breast cancer is more likely to develop in black women than white women. This is not true during the postmenopausal period. Sex: Breast masses are overwhelmingly a disease of women. Age: Women older than 40 years account for more than 80% of breast cancer patients. The median age of diagnosis is 64 years. History: Physical: Perform a thorough breast examination for any patient presenting with a breast complaint and any older woman presenting with unexplained weight loss, anorexia, or bone pain. Talk through the examination, giving extra instruction on how and when patients can perform breast self-examination at home. Causes: Lab Studies:
Imaging Studies:
Procedures:
| | TREATMENT | Section 6 of 10    | | Emergency Department Care: Consultations:
The goal of therapy is to eradicate the infection and minimize complications.
Drug Category: Antibiotics -- Therapy must cover all likely pathogens in the context of the clinical setting. Drug Name
| Nafcillin (Unipen) -- DOC for puerperal breast abscess. Treats infections caused by penicillinase-producing staphylococci. Used to initiate therapy when a penicillin G–resistant staphylococcal infection is suspected.
Because of occasional occurrence of thrombophlebitis associated with parenteral route (particularly in elderly persons), administer parenterally only for a short term (24-48 h) and change to PO if clinically possible. | | Adult Dose | 2 g IV q4h |
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| Pediatric Dose | 150 mg/kg/d IV divided q6h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
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| Precautions | To optimize therapy, determine causative organisms and susceptibility; >10 d treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); take cultures after treatment to confirm that infection is eradicated |
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Drug Name
| Vancomycin (Vancocin, Vancoled, Lymphocin) -- DOC for patients with puerperal breast abscess who are penicillin allergic. Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Useful in treatment of septicemia and skin structure infections. Indicated for patients who cannot receive, or have failed to respond to, penicillins and cephalosporins or who have infections with resistant staphylococci.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after the third dose drawn 0.5 h before next dosing. Use CrCl to adjust dose in renal impairment, prn. |
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| Adult Dose | 1 g IV q12h |
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| Pediatric Dose | 40 mg/kg IV tid/qid |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Erythema, histaminelike flushing and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants |
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| Pregnancy | C - Safety for use during pregnancy has not been established. |
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| Precautions | Caution in renal failure and neutropenia; red man syndrome is caused by too rapid IV infusion (dose administered over a few minutes) but rarely happens when dose given as 2-hour administration or as PO or IP administration; red man syndrome is not an allergic reaction |
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Drug Name
| Clindamycin (Cleocin) -- DOC for nonpuerperal breast abscess. An alternate DOC for patients with mastitis who are penicillin allergic.
A lincosamide useful as treatment against serious skin and soft tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci.
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition. |
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| Adult Dose | 300 mg IV/PO q6h |
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| Pediatric Dose | 20-40 mg/kg IV/IM tid/qid |
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| Contraindications | Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis |
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| Interactions | Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
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| Precautions | Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis |
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Drug Name
| Ampicillin-sulbactam sodium (Unasyn) -- Alternative DOC for nonpuerperal breast abscess. Drug combination that utilizes a beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens. |
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| Adult Dose | 1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin |
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| Pediatric Dose | 3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
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| Precautions | Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction |
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Drug Name
| Dicloxacillin (Dycill, Dynapen) -- DOC for mastitis. Bactericidal antibiotic that inhibits cell wall synthesis. Used to treat infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected. |
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| Adult Dose | 500 mg PO qid |
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| Pediatric Dose | 12-25 mg/kg/d PO divided qid |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Decreases efficacy of oral contraceptives; increases effects of anticoagulants; probenecid and disulfiram may increase penicillin levels |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
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| Precautions | Monitor PT in patients taking anticoagulant medications; toxicity may increase in renal impairment |
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Drug Name
| Oxacillin (Bactocill, Prostaphlin) -- Bactericidal antibiotic that inhibits cell wall synthesis. Used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected. |
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| Adult Dose | 500-1000 mg PO q4-6h
150-200 mg/kg/d IM/IV divided q6h |
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| Pediatric Dose | 50-100 mg/kg/d PO divided q6h
150-200 mg/kg/d IM/IV divided q6h; not to exceed 12 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Oxacillin decreases effects of contraceptives and tetracycline; administered concomitantly with disulfiram and probenecid, may increase oxacillin levels; effect of anticoagulants increase with large IV doses of oxacillin |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
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| Precautions | Caution in impaired renal function |
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Patient Education:
Medical/Legal Pitfalls:
 | btw can i ask u a question?? what is the difference between a cyst and a mass?? |
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