Emergent Breast Ultrasound - HD

Introduction and Disclosures

Thanks so much, and good morning.

These are my disclosures, none of which are related to this presentation.

This morning we're just going to be talking about some lesions that may require immediate or urgent intervention, as well as some that really should be left alone.

The management of many of these lesions is the same.

Breast Anatomy Review

Just for review, the breast lives in a fascial envelope on the chest wall, and it's the superficial pectoral fascia, which splits and has a posterior layer just anterior to the muscle.

And an anterior layer lying just beneath the skin supporting the breasts are the suspensory ligaments of Cooper, the Cooper's Ligaments that are connective tissue, and that bind the fat loles.

And you can see very easily on mammography as well as on with ultrasound.

Cut at various depths, are the segments, the breast duct and labial segments, which you can see here, and where many of these processes, the inflammatory processes begin, as well as other diseases of the breast are in the terminal duct lobular unit or the surrounding stroma.

Classification of Benign Breast Disorders

A very fine book came out many years ago. It's now in its third edition, published by Elsevier. It's in 2009. It's Mansel and Webster, benign Breast disorders.

And a classification of benign breast disorders was presented with an acronym Andy, whose letters stand for aberrations of normal development and involution.

And this classification takes you throughout life.

The early developmental stages, the teen years through 25, where you find fibroadenomas and in at pubescence, sometimes a adolescent hypertrophy, which can be unilateral, then cyclical changes of the adult during the reproductive years from 25 to 40.

Breast pain, nodularity epithelial hyperplasias of pregnancy as the breast enlarges under endocrine stimulation, involution begins at the age of 35 and continues on for another 20 or 25 years with all of these structures within the breast affected.

You'll find cyst formation and as a terminal duct lobular unit type of lesion sclerosis, aosis.

And then within the ducts, you'll find enlargement and then per ductal mastitis, which can be painful and require the treatment that we apply for other inflammatory lesions.

Epithelial turnover is also common there where you would have hyperplasia progressing in some instances to atypia, epithelial atypia which need intervention and then going on and not addressed in this book to malignancies.

Non-ANDI Conditions: Focus on Breast Abscesses

Non Andy conditions are most concerned with here. They have well-defined etiologies unrelated to the time of life.

And lactational abscesses are common, the literature is really pretty poor as you try to review it.

And the best review that I've seen and it's now aging a little bit, it was published in Radiographics in 2011, came from Montreal and Isabelle Trope was the first author.

This is about breast abscesses and the illustrations are excellent.

They, the comment that's made here and this was the introductory paragraph and it's something to take home, is that the available literature on treatment of breast abscesses is imperfect.

A lot of it is ad hoc and no clear consensus exists on drainage, antibiotic therapy and follow up.

One's experience goes very much into what we do with these patients.

Emergent or Urgent Breast Symptoms

Emergent or urgent for patients, breast symptoms are all urgent. There's redness and swelling, ecchymosis and discolorations ulceration with or without drainage, enlarged painful axillary lymph nodes, which occur with inflammatory processes as well as breast cancer.

And we have to be very careful with these to keep in mind that there is lurking always an inflammatory breast cancer, advanced breast cancer mimicking the breast abscess fever, focal pain, and some duct discharges.

Bring these patients in.

Patient Sources

How do they come to us? And from where?

The patients may come from the obstetrician's office, a lactating patient with a problem from the surgeon who has just treated that patient for cancer or has performed a cosmetic procedure or reconstruction.

And the oncologist either medical and or radiation, who has immunosuppressed that patient, we also may find coming to us directly those patients who've suffered a traumatic episode.

We need to be available and ready to address these problems.

Patient Evaluation

What, how do we evaluate these patients? The history, including timing, is first, when did the trauma occur? What was it? How did it happen, pregnancy or lactation and recent or remote surgery.

All these histories are what you would take in with any patient, diabetes or immunosuppression.

And then some risks of development of inflammatory processes, including abscesses, smoking. That's a big risk factor. I think it's unrealized.

And then piercings, including nipple ring placements.

Physical exam, first, observe the patient look at the breast. The patient may have a cord in the upper route or quadrant, representing mondor.

And there there's nothing much you need to do. It's a self-limited condition.

Or you may see evidence of mastitis in redness and swelling and try to do a physical exam.

And there you'll see just how acute the problem is if by how close the patient lets you come.

Masses, no masses, whatever you find from the ultrasound examination and will guide you towards the appropriate therapy.

Ultrasound Evaluation

With ultrasound, make certain that you look in the area that's symptomatic, but extend your field around it because frequently there are extensions of abscesses.

The collections may infiltrate the surrounding tissue and make certain too that your depth of field includes the pectoral muscle so that you don't miss a deep lesion.

Is an intervention necessary. That's the next question you ask yourself.

And in the case of lactational abscesses and other patients who have clinical findings of an inflammatory process, it's usually abscess versus mastitis.

Normal vs. Abnormal Findings

Let's look at the image on your right, which is a patient who was asymptomatic a norm. She may have had something on her contralateral breast, but here is a very normal picture of the tissue of a young patient who would have mammographically dense breasts.

There is a thick layer of echogenic fibro glandular tissue. The comparative tissue, the tissue relative that to which your echogenicity is compared is fat, which is less echogenic.

This is normal. And this tissue you can see evenly the very fine ductal structures winding their way through. They are a fraction of a millimeter in diameter.

You can see also the Petra muscle deep to it and everything looks orderly.

Compare this with a lactating patient who is in pain, has redness and swelling on her breasts, the area of fibro glandular tissue.

And the tissue looks more less echogenic and more hypoechoic during lactation itself. But this is becoming disorderly looking.

This patient then left, and there's no abscess here. There is just not poor penetration deeper. These ducts are going in various directions.

The patient left with a prescription for antibiotics, which he took for seven to 10 days.

And here's again, the same thing on the left. Two months later, she at the conclusion of the antibiotics, she thought things had resolved, but now we have a very large abscess collection with a lot of detritus within it and surrounding response.

Drainage Techniques

These are what you might use to introduce if you use an introducer for breast biopsy needle. But for an abscess of this size, you could use this, remove the stylette attached tubing and then a syringe at the end of the tubing and try to aspirate the fluid.

These are stiff and as metallic areas, they probably are less likely to occlude with the material that you're withdrawing.

But it's just one of many ways to do the abscess drainage.

This diagram comes also from that book on benign breast disorders.

And the most common locations of what you see here, a subcutaneous abscess in fat bulging the tissue are a sub arrear abscess that may not be related to lactation or maybe and then here within the parenchyma of the breast and many lactational abscesses will occur here.

There is some fear about mil fistula after aspiration. We've seen very few of those and then the deep ones.

So it's important to look deep and make certain that you don't have a retro mammary abscess that is actually proceeding through the muscle.

Mastitis can progress as I've shown you to abscess despite antibiotics. So these patients need to be followed up.

They have varied ultrasound appearances. Most common is to find them during the first month of lactation and at weaning, the entry of the pathogen which is most often sta aureus is through a cracked nipple.

The method of therapy is also most often ultrasound guided serial drainages. You can place self retaining catheter catheters usually six or eight French but the serial drainages seem to be just as effective.

They're less invasive with less scarring and less patient concern with catheter management and easier for them to continue breastfeeding.

They were very popular after a review or report came out from Scandinavia about using catheters for abscesses that were greater than three centimeters in diameter which is actually a very small not a very large abscess collection, but they are losing favor in most breast centers.

Surgical incision and drainage is no longer standard of care. And this is acknowledged by surgery as well as our own experience, which supports percutaneous drainage for treatment failures.

After repeated drainages, its appropriate to call for surgical consultation as well as with extensive multiloculated collections.

When you begin to aspirate, you can break septa by moving your needles around.

So the multi lod or some lolls can be aspirated percutaneously, but some may not. Or if the abscess has ruptured through the skin already it can be completed with surgical incision and drainage.

This photograph shows you a lactational abscess which may be about to break through the skin here.

And on the rela the cracked area of skin through which the pathogen entered the nipple pig.

The arre or pigment had changed during pregnancy as we find not uncommonly in man cell's report about abscesses.

It is said that 9% of breastfeeding women will experience an abscess.

Some images here, this is an example of what you might see commonly of an abscess. It's beginning to wind its way into the subcutaneous fat.

It has some heterogeneous material at its base through transmission. You see the abscess itself extends laterally.

You may think it ends here, but it doesn't. It ends here.

The question is and this is a trapezoidal opening of your image is there another collection adjacent to it which is contiguous with this?

And do you need to extend your procedure? So important to continue your study before you begin the procedure, to include areas around the abscess in all directions.

Another abscess. This is ocular. These are orthogonal views.

And I'm showing you this to show you the common pattern of vascular pattern which is rim vascularity around an abscess. This one was easily drained percutaneously.

Another appearance is a more solid appearance. And what you can see here is this, we published in Birads with its very pretty.

It came from Italy submitted by Giorgio Rosado who was an Italian radiologist who subspecialized in breast ultra synology.

And here you find this beautiful rim abscess but is the content solid? Is it liquid? It had thick material that was difficult to aspirate, and sometimes in completely aspirated but possible.

A colleague in a much more recent case working with a fellow addressed this as a solid lesion. The patient was 20.

She was not lactating and I don't know whether she had a piercing or nipple rings or what have you.

But this was a scout bio, a scout image for a core biopsy that they planned. Yes, it was the same kind of material that was found in this smaller abscess and possibly drainable.

This was not recognized as fluid anteriorly. The histology of the core biopsy was acute abscess with nothing else.

So things can look that way.

Imaging Large Lesions

How do you image large lesions, either panoramic sweeps extended fields of view, supine automated ultrasound and I'll show you a couple of examples, are great for multiple extensive bilateral processes but they don't work for the don't touch me very excruciatingly painful abscesses.

You need compression of a paddle and you can't just as you can't do mammography even though the compression is far less with ultrasound it is too much for these patients who are difficult to touch.

Splicing method with dual screen and where you oppose the two edges. Trapezoidal display is another one which I shared you.

And then you may need a lower frequency transducer for penetration of very thick tissue or to get back to the pectoral muscle.

This is a nine centimeter abscess, also percutaneously drained being shown being seen with the panoramic sweep.

Pathogens and Antibiotics

What are the pathogens and some of the antibiotics that are used? Staph aureus as I mentioned, others may include MRSA methicillin resistant staph streptococcus Biogen e coli bacter and then a variety of antibiotics.

I should say that some of the slides are not in your in what you have for this lecture. Some you do. But if anyone wants any of these or or all of them, just let me know and I'll be glad to send you the presentation.

So this these are the current antibiotics that are used. Just note that for MRSA clindamycin which seems to be used ly by most obstetricians is effective against methicillin resistant staff.

Therapeutic Procedure for Abscess Drainage

The therapeutic procedure confirmed the abscess with ultrasound. Antibiotics are important, but you can aspirate and drain before antibiotic therapy is instituted.

Used to be thought that you needed coverage while you were doing the procedure, but you really do not. It's important to get the pus out of the abscess.

And then the antibiotics can be instituted written consent, cleanse the area with a sterile field, drape it.

And then however you prepare and disinfect your transducers before use is what you need to do. There's no need to sheath these transducers.

You have a sterile field and the needle, then whatever needles you are using should never touch the probe for any procedure.

Lidocaine one or 2%, 2% actually works a little bit better in these patients with a make a one milliliter a one milliliter can be placed into a skin creating a wheel with a tuberculin syringe.

These are syringes that hold about a milli a milliliter with needles that are a half inch in length very fine needles, 26 or 27 gauge.

And through the skin wheel, you can use a larger needle to inject 10 ml or more of lidocaine around.

And in the cavity, you can aspirate a few ml for grams stain and culture and sensitivity, it's very important to do that.

If there's no pus or other liquid, then you want to consider biopsy do so, but at least send whatever you can for analysis, aspirate or drain, usually with a 16 gauge or an 18 gauge needle with tubing if there if it's a large abscess, if not a syringe will do.

If the material is very thick, you can use a 12 or a 14 gauge needle in syringe or introducer.

As I've mentioned before, there have been a report or two, and we did try it with limited success using a vacuum device with an in non cutting mode, you need a wired device there.

But for a very large abscess or one that's quite thick that might be something you might need, you might want to try for large abscesses.

This trocar approach can be used to place a six or eight gauge French self retain catheter.

And once you've emptied the cavity you can rinse it with sterile saline until the saline returns fairly clear.

It takes quite a long time to empty some of these abscesses, as I'm sure some of you know.

Then when you finish the procedure notify the referring physician and arrange for antibiotics if not already started.

Check gram stain and culture to see if there's need to change what has been the initial antibiotic given to the patient.

The patient can continue to breastfeed from the unaffected breast and empty and pump the affected breast to keep it as free of milk as possible.

The milk is a good culture medium and stasis really is one way that you can develop abscess.

These are some of the most commonly used antibiotics but any of the obstetricians and you can prescribe it in conjunction with the referring physician if you would like.

Galactoceles and Post-Lactational Involution

The galacto seal is something that you find in many lactation lactating patients. It's not urgent as variable.

Variable images on ultrasound assists with layering complex mass, representing an oil cyst or fat necrosis, or a solid appearing mass on mammography.

Sharply defined, rounded fat density mass with small soft tissue density nodules. They don't calcify.

And mammography can show you additional lesions that are not palable.

This is a typical appearance of a couple of galacto seals one sitting right on top of the other with the little nodules that I described to you.

If you aspirate these, you'll get back milk. Is it necessary to aspirate any or all of them? Probably not.

Post lactational involution is something to know about lactation will cease seven to 10 days after breastfeeding has stopped with phagocytosis removing the accumulated secretory products.

When would a patient who is of screening age be able to return in three to four months? And the resting state will come back.

There'll be an increase in fat in the breast. The fat will be less, the breast will be less dense after involution.

If there's need for mammography during the period of lactation, the patient should empty your breasts either through feeding or pumping.

And it's not a worthless exam. You can see calcifications if necessary and a variety of other things.

Other Lesions: Granulomatous Mastitis and Post-Surgical Collections

Post-surgical collections high risk patients infected cysts and then duct tasia related lesions are also possible.

There is a process called granulomatous mastitis which is a subacute chronic hard to treat.

And I'll show you an example. This is Dr. Tasia and abscess, often recurrent here. Aspirate culture and sensitivity.

This duct is filled with puss and there's edema in the surrounding tissue.

They may recur frequently and require surgical surgical excision.

And even after that recur around a foreign body as I think we know in other areas you may have abscess formation.

This patient was who had a left mastectomy and chest wall radiation. Also had a valve replacement which required a median sternotomy.

And the abscess which is going from the sternum. Here's the edge of the sternum and the sternal tissue behind it.

The sternal bone going from the posterior aspect all the way through the skin where it was draining. So there was a fistulas tract.

Trauma-Related Lesions

Other lesions possibly urgent are maybe related to trauma falls, seatbelt injuries, large hematomas fat necrosis scarring.

For most of these, no intervention is necessary and you treat them symptomatically. Those patients may come to the er.

Leave Me Alone Lesions

Here is a leave me alone lesion. This is a post-surgical seroma, six months after lumpectomy and radiation therapy in a 79-year-old asymptomatic patient.

The mammogram that corresponds shows you this fluid collection and it's starting to show speculation around the edges.

This is this scarring that will occur slowly after the fluid is resorbed over a period of time which may be a couple of years.

So this don't touch the if there's an axillary sampling or a dissection and a fluid collection is there that is generally drained by the surgeon as you see here.

Here's another leave me alone lesion. This is an epidermal inclusion.

And these are just beneath the skin subdermal and sebaceous cysts.

If you needle those to remove the contents there will be an extrusion of material which is very irritating and may cause abscess formation.

If this is something that bothers the patient it can be excised surgically along with the capsule. So those are not for us to do.

Vascular Lesions and Inflammatory Carcinoma

Vascular lesions are rs which I mentioned superficial venous thrombosis.

And then maybe once a year, if your volume is high or possibly twice, you'll find a pseudo aneurysm after stereo biopsy. I'll show you two cases of these.

And then don't forget inflammatory carcinoma.

This is mond's. It's a thrombose vein. You can see it beating here and that the axial view of it and the vascularity which is not there.

So these are self-limited. They need to be followed up for resolution.

And usually in three to four weeks if there's pain, a symptomatic relief is what you can offer.

This is a pseudo aneurysm after a stereotactic biopsy. And generally they can be thrombosis after you stand there and compress vigorously for 15 to 30 minutes.

It may take longer than that. And if it does take more than an hour or so give the surgeon a call.

Here this is the last case I'm showing you. This is inflammatory carcinoma and what this is is automated ultrasound with a 15 cm wide transducer a linear transducer that acquires the image with reconstructions in coronal view where you see the entire breast at that level and a sagal reconstruction.

So looking at this, you see the pot orange very nicely. The dilated pores and the swollen breast tissue.

Looking at the acquisition, the very thickened skin it's more than a millimeter in thickness and possibility of masses within the breast parenchyma which you do see better in confirm on the sagittal reconstruction.

So this is inflammatory carcinoma. And yes, you can biopsy these masses possibly do a skin punch biopsy for the diagnosis.

And if you make a mistake and send the patient home on antibiotic therapy you won't be able to drain anything.

But if you send the patient home out and she may feel better but she will be back to you and you make sure that you see her within a week to 10 days and the right thing will be done.

Conclusion

In conclusion, these are my take home messages regarding emergent breast ultrasound.

Symptomatic lactating patients should be seen emergently and evaluated with ultrasound if mastitis is diagnosed. Antibiotic therapy and ultrasound follow up in seven to 14 days is important.

If an abscess is found, make certain that you send to fluid for gram stain culture and sensitivity and then attempt to empty it post-surgical fluid collections and lumpectomy and radiation therapy treated asymptomatic cancer patients are leave me alone lesions as are the dermal lesions that I mentioned.

First line treatment of breast abscesses this is important and it's accepted by surgeons as well as breast imagers is no longer surgical.

IND know, but know when surgical intervention is necessary. And don't forget inflammatory carcinoma as an insidious mimic of breast abscesses.

And I thank you very much for being here.