Mastitis

Here’s the RoshReview Question of the Week:

A 30-year-old woman presents to the office with right-sided breast swelling and pain. She is 8 weeks postpartum from a spontaneous vaginal delivery of a term infant and is currently breastfeeding. She states her right breast is very painful, swollen, and red, and she has had a fever for the last 2 days. Which one of the following is the most appropriate next step for this patient?

• Breast ultrasound

• Dicloxacillin

• Discontinue breastfeeding

• Vancomycin

Check your answer and get a special discount at the link above!

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For more on breastfeeding, see our prior breastfeeding episodes (Part I and Part II) with Dr. Erin Cleary 

Before we get into mastitis… Breastfeeding is challenging!

• There are many benefits to breastfeeding

  • Decrease in breast cancer, ovarian cancer, diabetes, HTN, heart disease 

  • Recommendation for breastfeeding for first 6 months of life or longer 

  • Benefits to the infant as well 

• However in the US, as high as 45% of women report early, undesired weaning

  • Can be because of many things; nipple pain, perception of low milk supply, difficulty with latch

  • Other social factors, ie. limited access to maternity leave, barriers to breastfeeding in the workplace  

  • Depression, previous negative breastfeeding experiences 

• Also, many things can occur in breastfeeding that can be a challenge 

What can look like mastitis? 

• Engorgement

• Physiologic breast fullness that often occurs between day 3-5 postpartum 

• Typically reassuring sign that mature milk is being secreted 

• However, can cause symptoms of distention, pain, tenderness, firmness and even fever (usually lower fever) - which can make it easy to confuse with mastitis 

• Slightly swollen and tender lymph nodes 

• Can sometimes be very pronounced and there should be anticipatory guidance 

• Treatment:

  • Overall, data on prevention is limited

  • Can try acupuncture, hot and cold packs, cabbage leaves - but all from systematic reviews have found insufficient evidence to recommend a particular treatment regimen 

  • Can use milk expression to relieve some symptoms 

• Persistent breast pain with feeding

  • Can be caused by many things  

    • Nipple damage from baby or with overuse/misuse of pump

      • Infant with tight lingual frenulum “tongue tie” - can get frenotomy or frenectomy 

      • Can help observe pumping session and adjust level of suction or fit of flange with lactation consultants  

    • Psoriasis, eczematous conditions - need to apply emollient and reduce identifiable triggers 

    • Candida infections - topical azole and antifungal ointment or cream are ok, or even oral fluconazole 

    • Herpes simplex or zoster - can be seen a small, clustered tender vesicles

      • Treatment with oral antiviral therapy 

      • Stop breastfeeding on that side temporarily 

• Galactocele - milk retention cyst 

  • Usually just a collection of fluid that is caused by obstructed milk duct - usually soft cystic masses 

https://creogsovercoffee.com/notes/2019/6/16/breastfeeding-part-ii-facts-and-myth-busting

• Infant’s chest rests against maternal body

• Infant’s chin touches the breast, tongue is down 

• Lips flanged outward

• Little or no areola is visualized 

• Rhythmic sucking present 

• Audible swallowing present

• Latch is not uncomfortable or painful and nipple is not injured or misshapen after breastfeeding  

What is mastitis? 

• Defined as inflammation of the breast 

  • Can occur spontaneously, but today we’re talking just about mastitis in the context of breastfeeding 

• Can occur in about 10% of patients who are breastfeeding 

  • Is especially problematic because it can lead to discontinuation of breastfeeding 

• Risk factors:

  • Infant attachment issues - ie. short frenulum, cleft lip/palate

  • Cracked nipples, local milk stasis 

  • Missed feedings 

  • Poor maternal nutrition 

  • Previous mastitis 

  • Primiparity

  • Use of breast pump 

  • Yeast infection 

• Diagnosis

  • Usually is made clinically 

  • Presentation usually is:

    • Localized, unilateral breast tenderness + erythema 

    • Fever - usually high! >101.0F (38.5C)

    • Can also have malaise, fatigue, body aches, headache 

    • Rarely will need to have culture to identify organism 

  •  On exam: will find redness, tenderness on one aspect of a breast (can be in different quadrants)

    • Be sure to examine for fluctuance - is there an abscess?  

  • When to get imaging:

    • If you suspect abscess on physical exam 

    • If symptoms are not improving despite medical management 

    • Usually can diagnose via ultrasonography  

• Treatment

  • Breastfeeding technique

    • Lactation consultation to improve technique 

    • Counsel that patient should not stop breastfeeding or pumping on that side, as stopping can lead to milk stasis and more likely to develop abscess 

    • Can continue breastfeeding!  

    • Usually, the baby is already colonized by the same organism 

  •  Medical management

    • Antibiotics are usually needed for 10-14 days

    • Possible treatments include:

      • Augmentin 875 mg BID 

      • Keflex 500 mg 4x/day (hard to do 4x/day meds) 

      • Clindamycin 300 mg 4x/day - can be used against MRSA 

      • Dicloxacillin 500 mg 4x/day 

      • Bactrim DS (160mg/800 mg) BID - can be used against MRSA, but usually may want to avoid in patients with preterm infants 

• When to refer

  • Abscess

    • Usually needs to be drained 

    • Can often be done at the bedside, and usually will not need to refer to breast surgery if you feel comfortable 

    • However, can depend on individual provider’s level of comfort  

  •  Abnormal presentation/lack of response to treatment

    • Most mastitis should resolve after initial treatment, and recurrence is not common, but can result from inappropriate or incomplete antibiotic therapy 

    • Most abscesses do not recur 

    • Inflammatory breast cancer can resemble mastitis at times, but may be differentiated by skin thickening as well as axillary lymphadenopathy 

Mastalgia

Mastalgia is breast pain. It’s a super common complaint, but one that we don’t spend a lot of time learning about in OB/GYN residency.  But a systematic approach and knowing a little bit of evidence makes this an easier problem to tackle!

There are 3 types of breast pain: cyclical, noncyclical, and extramammary 

Cyclical 

• Characterizes about ⅔ of patients with mastalgia.

• Associated with hormonal fluctuations of menstrual cycles, usually starts about a week prior to menses.

• Usually bilateral, most severe in upper outer quadrants.

• Caused by stimulation of ductal elements by estrogen.

• Can also be associated with pharmacologic hormonal agents (ie. OCPs, HRT).

Noncyclical 

• Represents ⅓ of women with true mastalgia.

• Does not follow a menstrual pattern.

• More likely to be unilateral or located in one position on a breast, etc. 

• Causes are highly variable:

  • Large, pendulous breasts;

  • Diet and lifestyle (high fat diet, smoking, caffeine intake);

  • Breast cysts; ductal ectasia (meaning distention of subareolar ducts due to inflammation unrelated to infection);

  • Mastitis;

  • Inflammatory breast cancer;

  • Hidradenitis suppurativa;

  • Mondor’s disease (thrombophlebitis of the breast);

  • Trauma;

  • Certain medications, such as some SSRIs and antipsychotics, as well as spironolactone.

Extramammary - not a “true mastalgia.” 

• Basically referred pain from the intercostal nerves, or chest wall pain likely due to muscular injury.

How common is mastalgia, and what are risk factors? 

• Very common - up to 70% of women in the US will experience some type of mastalgia in their life.

• Those at higher risk are older women, those with larger breast size, less fit and/or physically active.

How do you approach the evaluation of mastalgia? 

1. History characterizing questions are super important with mastalgia! They can help to elicit the differences commonly seen between the cyclical and non-cyclical types, as well as find other potential causes of pain that are not true mastalgia.  

   • Where is the pain? Is it bilateral or just on one side? 

   • What does the pain feel like? Aching? Pinching? 

   • When does the pain occur? Does it occur around your period? 

   • Do you take any hormonal medications? 

   • Is it associated with other types of pain, like neck, back or shoulder pain? 

   • Have you had a fevers/chills/systemic symptoms? 

   • Have you had any recent trauma to the chest? 

   • Does the pain affect daily function? 

   • Complete medical, surgical history etc. 

2. Physical the breast exam can help to rule out any obvious causes, such as infection, mass or malignancy.

   • Examine for evidence of malignancy: mass, skin changes, or bloody nipple discharge.

   • Make sure you examine all 4 quadrants of the breast as well as the chest wall.

   • May have to have the patient lay on their side to be able to examine the chest wall when the breast falls away from the chest wall.

3. Imaging/Labs Imaging is not always necessary, but can be in the right circumstances:

• If mass, skin changes, bloody nipple discharge → mammography with or without ultrasound.

• If no suspicious findings, may not necessarily need imaging, but will depend on presentation as well as if they are due for annual screening anyway.

• Chance of having breast cancer with no abnormality on physical exam or imaging is about 0.5%. 

How do you treat mastalgia? 

• Reassurance

  • Many times, women just want to know that their breast pain is normal and that they do not have breast cancer!

  • Studies have demonstrated this will be enough to satisfy 78-85% of women with normal findings.

  • Approximately 15% of women will need some other kind of treatment.

• First line therapies

  • Physical support - well-fitting bra for support, warm compress or ice packs or gentle massage.

  • Over the counter analgesics - Tylenol, NSAIDs; topical NSAIds may also be useful.

  • Change in or cessation of hormonal medications 

• Second line - if still having debilitating breast pain after first line treatments:

  • Tamoxifen - 10 or 20 mg daily, but can be associated with vasomotor symptoms of menopause.

  • Danazol - only FDA-approved treatment for mastalgia (fibrocystic breast disease) - usually around 200 mg daily.

    • Can be androgenizing, so avoid if planning pregnancy.

    • Rare hepatotoxicity with large doses (>400mg).

• Other therapies not proven by randomized trial data:

  • Lifestyle changes (weight loss, stopping caffeine, low fat diet - 15% fat).

  • Evening primrose oil.

  • Vitamin E.

    • Many of these are offered and available over the counter, and have not demonstrated evidence of harm, either! So they may still be useful in your anti-mastalgia arsenal.

Breast Cancers and Treatment Knowledge for the OB/GYN

Today we welcome back Dr. Edmonson for part II of our breast cancer chat. Check out last week’s post for screening and imaging information.

From a radiographically-guided core breast biopsy, there’s a lot of things that can come back. Today we’ll focus on the pathologic concerns. Dr. Edmonson breaks this down into:

Atypical Ductal Hyperplasias / Atypical Lobular Hyperplasias / Lobular Carcinoma in Situ
These lesions predict a risk for breast cancer in the future, but are not actually cancer. These are all managed surgically, with an approximately 15% upstaging rate on final pathology after excision, most pronounced with ADH. The risk models we discussed last episode can then give an updated risk of breast cancer which may alter screening strategy (i.e., if risk exceeds 20%, MRI may be used as an adjunct). Additionally, using risk-reducing medications such as tamoxifen or raloxifene may also become appropriate.

Ductal Carcinoma in Situ (DCIS)
These are non-invasive cancers which require lumpectomy or potentially mastectomy. Thereafter, radiation is usually recommended as well as risk-reducing medications such as tamoxifen or aromatase inhibitors such as anastrozole. There is a 20-30% upstaging risk at time of surgery, and additionally additional surgery may be required to get negative surgical margins as there is no reliable intraoperative technique to detect margins.

Invasive Cancers (Invasive Ductal Carcinoma or Invasive Lobular Carcinoma)
With invasive cancer, different strategies exist. Surgery versus neoadjuvant chemotherapy or endocrine therapy may be considered based on extent of disease to reduce morbidity of surgery (i.e., more limited lymph node dissection which would reduce risk of lymphedema from axillary dissection). New surgical techniques exist now as well including lymphatic reanastamosis that is helping to improve morbidity after these surgeries.

Invasive lobular carcinoma can be difficult to identify. These are less aggressive, but they often don’t show up well on imaging and are difficult pre-operatively to get good margins.

After A Diagnosis
OB/GYNs can help to reassure patients and connect them to breast surgeons. Fewer breast cancers are requiring chemotherapy, which is often a patient’s greatest fear. Surgical techniques are improving and reconstruction is widely available, including skin-sparing and nipple-sparing techniques.

Screening will be guided by the breast surgeon. This depends more and more on the individual, the pathology and tumor characteristics, and risk for local recurrence. Recall that patients on tamoxifen are at higher risk of VTE and at higher risk of endometrial hyperplasia.

Benign Breast Disease

Today’s episode suggestion comes to us from Shadae Beale, a resident at Meharry Medical College. Thanks for listening! And be sure to send us your ideas through the website or via email!

We kicked off today’s episode with a vignette:

24 yo F G1P1 with 10 year history of type 1 diabetes presents with right breast mass that she palpated in the shower. She is currently breastfeeding her 9 mo old baby. She states that she has had some pain in her right breast, though no redness or swelling, and that she has always had “lumpy breasts.” She is worried because her 78 yo grandmother was recently diagnosed with breast cancer. No other breast or ovarian cancer in her family. On exam, she has lumpy, cobblestone texture of both breasts, with free-moving tissue throughout. There is one 2x2cm firm, mildly tender, mobile mass in the R breast at the 2 o’clock position, approximately 1 cm from the nipple. No axillary lymphadenopathy. 

Now we imagine that if this isn’t a likely scenario in your clinic time, it is on your test prep questions. What do you do with this patient? Let’s first review a broad differential diagnosis for a likely benign mass:

Nonproliferative Breast Lesions 

• Breast cysts 

  • Simple cysts - benign, fluid filled mass; usually discrete, compressible, or ballotable solitary mass 

  • Galactocele - milk retention cyst common in women who are breastfeeding 

• Fibrocystic changes - common, especially in premenopausal women; may cause breast pain 

• Lipoma - mature fat cells 

• Fat necrosis - can develop after blunt trauma to the breast; can also occur after surgery (ie. breast reconstruction, radiation therapy); associated generally with skin ecchymosis 

• Breast abscess - localized collection of inflammatory exudate; can develop alongside mastitis or cellulitis; usually will have all the signs of infection! 

• Diabetic mastopathy 

  • Usually in women with longstanding T1DM 

  • Suspicious fibrous breast lumps, usually multiple 

  • Need to biopsy for diagnosis

• Idiopathic granulomatous mastitis 

  • Rare inflammatory disease of the breast - usually presents as a painful, firm and ill-defined mass that can have erythema and edema of the skin 
    

Proliferative Breast Lesions without Atypia 

• Intraductal papillomas 

  • Monotonous array of papillary cells that grow from the wall of a cyst into its lumen.

  • Most common cause of bloody nipple discharge (key to any vignette!)

  • Generally not concerning, but CAN harbor DCIS; can be solitary or multiple lesions. If bothersome or concern for atypia, surgical excision is performed.

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Intraductal papilloma. (C) WebPathology.

• Sclerosing adenosis - lobular lesion with increased fibrous tissue; no need to treat.

• Radial scar - complex sclerosing lesions; usually diagnosed after biopsy. Recommend excision, but no other treatment .

• Fibroadenoma 

  • Most common benign tumor in the breast, accounting for ½ of all breast biopsies 

  • Glandular and fibrous tissue, presenting as a well defined, mobile mass on exam.

Atypical Hyperplasia 

• Atypical ductal hyperplasia (ADH)

  • Proliferation of uniform epithelial cells with round nuclei fill part of the duct.

  • Standard of care after biopsy-proven diagnosis is surgical excision, due to risk of upgrade to ductal carcinoma.

• Atypical lobular hyperplasia (ALH)

  • Monomorphic, evenly spaced dyshesive cells fill part of the lobule; can also involve ducts.

  • Referral to breast onc should occur, as management varies based on other clinical risk factors.

OK, so now you have a differential — what do we still need to do for this patient in front of us?

Always starting off with a history is important. With respect the HPI, it’s important to know not only about the characteristic of the mass, but any changes to the mass and the timiing of changes. For instance, is it painful, but cyclically painful with menses? That would argue more for fibrocystic changes. Has it grown in size over the last 3 months and caused nipple inversion in the meantime? That’s more worrisome for malignancy.

Family history and social history are also exceptionally important. Smoking increases risks of certain breast pathologies. And family history is obviously tantamount to determining a patient’s risk for particularly early-onset breast cancer.

Physical examination should include both breasts, examined in both a sitting and recumbent position. Note asymmetry, skin changes, nipple changes, and the location of masses. Generally using clock face language is most helpful for your referral: i.e., “12:00 position, 3cm from nipple” is highly descriptive. Finally, a regional lymph node exam should also be performed. Generally this includes axillary and supraclavicular nodes.

Imaging is what we will turn to next. For the younger patient, targeted breast ultrasound is an excellent choice, as it’s more sensitive than mammogram in this population with denser breast tissue. It also allows for immediate biopsy should the reading radiologist decide it’s indicated. Diagnostic mammography is also a standard of care in anyone with a palpable breast mass who meets criteria for screening. Definitive diagnosis is achieved with biopsy — core biopsy for solid lesions, fine needle aspiration for cysts, or excisional tissue biopsy as another option.

Breastfeeding Part II: Facts and Myth-busting

Today we (finally!) sit down with Part II of our breastfeeding special with Dr. Erin Cleary to cover myths, facts, and advantages of breastfeeding.

There are only three main contraindications to breastfeeding:
1. In infants with galactosemia.
2. In mothers who are HIV+ in high-resource settings.
3. In mothers with human T-cell lymphoma virus.

There are a number of relative contraindications to breastfeeding:

• In a mother with Hepatitis A until she receives gamma globulin.

• In a mother with Hepatitis B until the infant receives HBIG and HepB vaccine.

• In a mother with Hepatitis C if coinfections present, such as HIV.

• In a mother with Varicella zoster (Chicken pox) while mother is infectious.

• In a mother with Active TB until mother has received 2+ weeks treatment

• In a mother with influenza

  • if the mother has been afebrile without antipyretics for >24 hours, and the mother is able to control her cough and respiratory secretions.

  • Oseltamivir or Tamiflu is poorly excreted in breastmilk

• In patients abusing IV drugs.

• In patients using marijuana:

  • (THC), the main compound in marijuana, is present in human milk up to eight times that of maternal plasma levels, and metabolites are found in infant feces, indicating that THC is absorbed and metabolized by the infant

  • Several preclinical studies highlight how even low to moderate doses during particular periods of brain development can have profound consequences for brain maturation, potentially leading to long-lasting alterations in cognitive functions and emotional behaviors

  • Breastfeeding mothers should be counseled to reduce or eliminate their use of marijuana to avoid exposing their infants to this substance and advised of the possible long-term neurobehavioral effects from continued use

Common Breastfeeding Myths/Misconceptions:

Infectious:

• You should breastfeed if you have mastitis, emptying the breast prevents stasis of milk

You can breastfeed in setting of acute respiratory, urinary, GU infections, continuation of BF acceptable

Imaging Sudies

• You can breastfeed if… You need medical imaging.

  • XRays do not affect milk

  • Mammograms may be harder to interpret when a patient is lactating, but this should not be a reason to defer recommended diagnostic imaging

  • CT/MRI with or without contrast do not impact breastmilk

  • XRays with contrast dye or imaging with radioactive material are also OK

  • Exception: thyroid scan using I-131

    • I-131 concentrates in breastmilk and at high levels can suppress baby’s thyroid function (or even destroy the thyroid) and increase risk of thyroid cancer.

    • Therefore it is important that breastfeeding be discontinued until breastmilk levels are safe (this depends upon the dose and ranges from 8 days to 106+ days). The half-life for I-131 is 8.1 days.

    • Hale recommends that when I-131 is used, breastmilk samples should be tested with a gamma (radiation) counter before breastfeeding is resumed to ensure that radiation in the milk has returned to safe levels.

• You can breastfeed if… You are pregnant!  

  • Increasing progesterone will decrease supply and cause breast/nipple sensitivity.  

  • Mature milk will be replaced by colostrum in the 2nd trimester.

  • Tandem feeding includes breastfeeding a newborn and toddler

• You can breastfeed if… You’ve had general anesthesia.  As soon as you are awake enough to hold the baby, the medication has metabolized and breastfeeding is safe.

• You can breastfeed if… You are on maintenance medications such as methadone and buprenorphine

  • There is a reduction in severity and duration of treatment of NAS when mothers on these medications breastfeed

• You can breastfeed if… You have an occasional alcoholic beverage

  • Alcohol concentration in the blood is in steady state with the milk, so delaying nursing or pumping until more alcohol is metabolized can limit exposure

• If direct breastfeeding is interrupted due to temporary separation of mother and child for any reason, the breastfeeding mother should be encouraged and supported to regularly express her milk.

  • Expression and storage of milk allows the infant to continue to receive milk if appropriate, and prevents stasis of milk and mastitis

In the setting of infection, prior to expressing breast milk, mothers should wash their hands well with soap and water and, if using a pump, follow recommendations for proper cleaning.