Mastodinia, galactocele, mastitis y absceso mamario.

MASTODINIA, GALACTOCELE, MASTITIS Y ABCSESO MAMARIO.

GALACTOCELE, MASTITIS Y ABSCESO MAMARIO.MARLON MIZAEL GARCIA HERNANDEZ MEDICO RESIDENTE IMAGENOLOGIA DIAGNOSTICA Y TERAPEUTICA.HOSPITAL REGIONAL DE ALTA ESPECIALIDAD DEL BAJIO.

MASTODINIA Y MASTALGIA.Lamastodinia(mastalgia cclica) es el dolor cclico mamario previo a la menstruacin, y suele estar asociado a otros sntomas que engloba el sndrome premenstrual (hinchazn generalizada, cambios de humor, aumento de peso). Suele exacerbarse en los ltimos aos de la menstruacin y desaparece con la menopausia.

La mastalgia es el dolor de mama sin una patologa mamaria adyacente, de predominio en los cuadrantes superiores externos, pudiendo estar asociado a sensibilidad y modularidad.Vera, et al. Guideline breast disease comity, society of obstetricians and gynecologist of Canada. SOGC Clinical Practice Guideline 2006;170-180.

Mastalgia o hipersensibilidad mamaria.2

MASTODINIA Y MASTALGIA.La clasificacin de la mastalgia cclica de Cardiff esta compuesta por tres tipos : cclica, no cclica y dolor en el trax.La mastalgia cclica afecta al 40% de las pacientes antes de la menopausia, principalmente antes de los 30 aos de edad y aproximadamente un 8% de estas mujeres el dolor es severo.La mastalgia raramente es un sntoma de cncer mamario reportndose solo entre el 15 y 18% ser parte de.Vera, et al. Guideline breast disease comity, society of obstetricians and gynecologist of Canada. SOGC Clinical Practice Guideline 2006;170-180.

Mastalgia o hipersensibilidadLa mastalgia cclica est relacionada con el final del ciclo menstrual, en la fase ltea2,10, asociada con ciclos ovulatorios, el dolor es bilateral, siendo ms severa en los cuadrantes superiores externos, el dolor puede continuar por muchos aos y se caracteriza por perodos de exacerbaciones y perodos asintomticos, pero usualmente desaparece en la menopausia mamaria.3

MASTODINIA Y MASTALGIA.La mastalgia no cclica descrita como un dolor agudo punzante y pesado, puede ser constante o intermitente y tiende a ser unilateral, no asociado con eventos menstruales.

Dolor bien localizado de manera subareolar o medial pudiendo ser bilateral. Vera, et al. Guideline breast disease comity, society of obstetricians and gynecologist of Canada. SOGC Clinical Practice Guideline 2006;170-180.


MASTODINIA Y MASTALGIA.Dolor de trax o mastalgia extramamaria.Es aquella que se presenta sin ningn patrn, en cualquier edad y casi siempre unilateral.En ella se considera la osteocondritis, de origen musculoesqueltico, surgido de trauma, dolor referido, artritisLa causa mas comn es por el uso de pectoral en actividad fsica localizado e cuadrante superior e inferior interno, pudiendo ser producido a la palpacin.Vera, et al. Guideline breast disease comity, society of obstetricians and gynecologist of Canada. SOGC Clinical Practice Guideline 2006;170-180.


GALACTOCELE

GALACTOCELEEs la lesin mamaria mas comn benigna (BIRADS II) que tpicamente ocurre en mujeres lactantes jvenes: aunque la mayora ocurre tras el termino de la lactancia.Sabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.

The term galactocele derives from the Greek words galatea meaning milky white and -cele meaning pouch9.7

GALACTOCELEPresentacin clnica:Tpicamente se presenta como una masa dolorosa palpable la cual ocurre dentro de semanas a meses.

Puede presentar uno solo o mltiples ndulos y puede ser unilateral o bilateral.

Sabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.

Patologa:Es esencialmente un quiste de retencin resultado de oclusin del ducto lactfero. El cual puede ser analizado tras su aspiracin percutnea mostrando en el anlisis bioqumico variedad de proporciones de protenas, grasa y lactosa.Macroscpicamente la leche dentro del galactocele puede parecer blanca y usualmente viscosa si esta fresca.GALACTOCELESabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.

Galactoceles are the most common benign breast lesions in lactating women, although they more frequently occur after cessation of breast-feeding,when milk is retained and becomes stagnant within the breast.9

GALACTOCELELocalizacin:

Aparecen con predileccin hacia la regin sub-areolar.

Galactoceles are cysts composed of cuboidal or flat epithelium containing fluid that resembles milk. They are often accompanied by inflammatory or necrotic debris.10

Mamograficamente:

La apariencia puede variar dependiendo de el contenido de grasa y protena y la consistencia de el liquido.Basado en esto los galactoceles pueden aparentar un pseudolipoma debido al importante contenido graso apareciendo radiolucido. Un quiste con nivel liquido graso producido por la diferencia de viscosidad entre grasa y leche liquida. Un pseudohamartoma cuando el contenido sea leche vieja y agua. GALACTOCELESabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.

The cysts form as a result of duct dilatation and are frequently encompassed by a fibrous wall of varying thickness that can be associated with an inflammatorycomponent.11

GALACTOCELEUltrasonograficamente las apariencias son muy amplias.

Qustica/multiquistica: 50%.Mezclada (qustica y solida): 37%.Solida: 13%.

La exploracin con Doppler muestra falta de flujo.Sabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.

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GALACTOCELE.Complicaciones:

Infeccin secundaria con el desarrollo consecuente de un absceso mamario.

En casos inciertos la aspiracin es recomendada en primera instancia, y el clsico hallazgo ser contenido lcteo.Sabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.

Chronic inflammation and fat necrosis can be seen due to cyst leakage (36). Aspiration is both diagnostic and therapeutic,yielding fluid milk when performed during lactation and more thickened milk fluid when obtained from older lesions after lactation has ended13

GALACTOCELEDiferenciales:

Adenoma lcteo: el cual es una lesin solida y puede mostrar flujo tras la aplicacin Doppler color.Absceso mamario: tiene diferente presentacin clnica pero puede ser una complicacin.Fibroadenoma: clsicamente ovoideo o en forma de almendra con borde liso, ecogenicidad interna homognea y realce acstico.Cncer mamario.Sabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.

GALACTOCELE TIPO PSEUDOLIPOMASabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.

Mammogram reveals an oval circumscribed mass whose radiolucency indicates a high fat content. Such a mass is mammographically indistinguishable from a true lipoma15

GALACTOCELE TIPO PSEUDOLIPOMA


US image shows a circumscribed echogenic mass mimicking a solid lesion. Note the intense posterior enhancement(arrows), which suggests a cystic mass with a nonwater content (complicated cyst). In the appropriate clinicalsetting, galactocele can be suspected and can easily be confirmed with fine-needle aspiration16

GALACTOCELE TIPO NIVEL GRASA LIQIUIDO.


Mammogram reveals an oval circumscribed mass with the characteristic fat-fluid level (arrows). In this type of galactocele, the milk content is fresh and fluid, allowing the fat to rise and the heavier water content to remain in the lower portion of the cyst17

GALACTOCELE TIPO NIVEL GRASA LIQIUIDO.Sabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.

US image also demonstrates the fat-fluid level (long arrows), with typical high and low echogenicity. Note that the fatty component has risen and occupies the upper (nondependent) portion of the cyst, whereas the heavier water content remains in the lower (dependent) portion. Note also the clot of fatty milk (cream) (short arrow) floating in the nondependent portion of the cyst owing to its intermediate density.18

GALACTOCELE TIPO PSEUDHMARTOMA


Mammogram shows an oval circumscribed mass with characteristic heterogeneous density due to the presence of fat radiolucencies in the mass (arrows). (19

GALACTOCELE TIPO PSEUDHMARTOMA

US image shows the mass, which consists of a mixture of hypoechogenic and hyperechogenic (*) areas.20

GALACTOCELE.


At initial presentation the lesion is moderately heterogenous on ultrasound. There is no skin thickening.21

Sabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.GALACTOCELE.

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Sabate JM, et al. Radiologic Evaluation of Breast Disorders Related to pregnancy and Lactation. Radiographics 2007;27:101-124.GALACTOCELE.

ultrasound of the area confirms a mixed echogenicity mass lesion measuring 13 mm in diameter23

MASTITISTrop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

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MASTITISSe refiere a la inflamacin del parnquima mamario dividindose en:

Mastitis aguda: Mastitis puerperal: ocurre por una infeccin usualmente por Staphylococcus durante la lactancia.Mastitis no puerperal: no relacionada a la lactancia y ocurre en mujeres adultas. Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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MASTITISMastitis de clulas plasmticas: inflamacin no comn sub areolar con infeccin bacteriana asociada.Mastitis granulomatosa.Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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MASTITISClnicamente el seno se presenta indurado, rojo y dolorosa.La retraccin del pezn puede ser evidente.La paciente suele presentar fiebre y leucocitosis.Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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MASTITISKalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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MASTITISMamograficamente:

Mastitis bacteriana puerperal y no puerperal usualmente su caracterstica es regiones bien definidas de incremento de la densidad y engrosamiento de la piel.

Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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MASTITISUltrasonograficamente:

rea bien definida de alteracin de la ecotextura con hiperecogenicidad representando la infiltracin e inflamacin de los lobulillos grasos alternando con reas hipoecoicas en el parnquima glandular y engrosamiento moderado de la piel.Pueden ser encontrados ganglios linfticos de tipo inflamatorio.Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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MASTITISSu complicacin es el absceso mamario.

Importante considerar como diagnostico diferencial el cncer mamario inflamatorio.Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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MASTITIS GRANULOMATOSAEnfermedad mamaria rara de origen desconocido.Clnicamente se presenta como una masa dura que puede envolver cualquier parte del seno.Afecta mujeres jvenes.Linfadenopatias reactivas pueden estar presentes en un 15% de casos.Causas inmunolgicas son consideradas como causa.


MASTITIS GRANULOMATOSAMamograficamente las caractersticas son variables, pudiendo ser hallazgos normales en pacientes con senos densos o ser masas de caractersticas benignas o malignas y densidad asimtrica focal. Ultrasonograficamente variable incluyendo apariencia tipo masa, estructuras hipoecoicas y disminucin focal de la ecogenicidad con sombra acstica.Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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MASTITIS GRANULOMATOSAEn RM el hallazgo frecuente es intensidad de seal asimtrica, siendo asimetra focal o difusa sin efecto de masa.T1: regiones hipointensas.T2: regiones hiperintensas.Fases contrastadas con refuerzo tipo masa, tipo anillo o nodular.Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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MASTITIS GRANULOMATOSAKalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

Granulomatous mastitis. (a) Subtraction MIP image shows a large mass and extensive dermal enhancement (arrow). (b) Axial subtraction image obtained a few months later after treatment with steroids shows marked improvement, with only mild residual dermal (arrow) and parenchymal (arrowhead) enhancement 35

MASTITIS Mastitis de clulas plasmticas:

Condicin mamaria benigna la cual representa calcificaciones de secreciones espesas en o inmediatamente adyacentes a los ectasicos ductos benignos.Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

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Afecta mas a mujeres mayores de 60 aos.Representa una inflamacin asptica de los senos por extravasacin de secreciones intraductales en el tejido conectivo periductal.


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Mamograficamente: calcificaciones gruesas, lineales en forma de varilla o cigarro. Midiendo a veces hasta mas de 10mm de largo. Tienden a ser bilaterales y simtricas en distribucin y orientacin con el eje largo apuntando hacia el pezn.


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MASTITIS DE CELULAS PLASMATICAS.Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

Mastitis de clulas plasmaticas39

MASTITIS DE CELULAS PLASMATICAS.Kalll, et al. Lesions of the Skin and Superficial Tissue at Breast. Radiographics 2010;30:1891-1912.

Mastitis de clulas plasmticas.40


MASTITIS DE CELULAS PLASMATICAS.

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ABSCESO MAMARIO

ABSCESO MAMARIOUn absceso mamario es relativamente raro pero significantemente una complicacin de la mastitis, el cual puede ocurrir durante la lactancia, particularmente en primparas.

El contexto clnico (rubor, calor, dolor, inflamacin) es la llave del diagnostico por imagen (particularmente por ultrasonido) pudiendo mimetizar otras entidades como un carcinoma mamario.Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

ABSCESO MAMARIOSe piensa que se desarrollan en un 11 a 15% de las mujeres lactantes con mastitis infecciosa.

Siempre habr un antecedente clnico de mastitis, el seno usualmente aparece caliente, rojo e indurado.

Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

ABSCESO MAMARIO.Un absceso mamario es definido como una masa inflamatoria la cual drena material purulento espontneamente o secundario a una incisin.

El microorganismo predominante es Staphylococcus aureus.Otros comunes tipos son el Staphylococcus epidermidis y el Proteus mirabilis.

Abscesos perifricos han sido asociados con mastitis durante la lactancia, pero reportes previos indican ser comunes en mujeres no lactantes.Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

ABSCESO MAMARIO.La bacteria entra por una pequea laceracin en la piel y prolifera al estancarse en los ductos lactferos.Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

ABSCESO MAMARIO.Clasificacin:

Por relevancia clnica y por tipo de manejo.

Abscesos puerperales: vistos en mujeres primparas.Abscesos no puerperales centrales: no relacionados con la lactancia, en mujeres jvenes fumadoras.Abscesos no puerperales perifricos: pocamente vistos, mujeres adultas con patologas asociadas como la artritis (toma de esteroides).Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

Peripheral nonpuerperal abscesses can also be encountered in women taking steroids or with recent breast interventions, such as those in the postoperative or postradiation therapy period, although most have no associated medical conditions (1). 47

ABSCESO MAMARIO.Suele asociarse en pacientes con diabetes.Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

ABSCESO MAMARIO.Caractersticas ultrasnograficas:

El ultrasonido es considerado el mtodo mas usado de imagen cuando un absceso mamario es sospechado.As como el mas usado para evaluar la evolucin y respuesta a terapia.Para propsitos de seguimiento debe siempre medirse n absceso en sus tres dimensiones y obtener un volumen.Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

ABSCESO MAMARIO.Caractersticas ultrasonografcas:

Coleccin hipoecoica mayormente multiloculada.No vascularidad dentro de la coleccin.Realce acustico debido al contenido liquido.Anillo vascular perifrico.


ABSCESO MAMARIO.Mamograficamente:

Raramente indicada y til.Utilizada solo para descartar malignidad en abscesos no puerperales.Mujeres alrededor de los 30 aos y en mujeres con abscesos puerperal de curso clnico prolongado.Monogrficamente las apariencias no son especificas.Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

ABSCESO MAMARIO.Mamograficamente:

Engrosamiento de la piel.Densidad asimtrica , masa o distorsin arquitectural.

(hallazgos no especficos para absceso o malignidad)Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

ABSCESO MAMARIO.Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

Puerperal abscess in a 31-year-old woman who noticed reddish discoloration in the lower inner quadrant of the left breast while breast-feeding her infant. After initial treatment with warm compresses, she was referred for US evaluation owing to lack of clinical improvement.

US image shows a heterogeneous slightly irregular collection that measures 4.3 4.1 2.0 cm (total volume = 18 mL), thus confirming the clinical suspicion of an abscess

US image shows aspiration with an 18-gauge needle, which yielded 14 mL of thick yellowish material. The aspirate was sent for culture

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US image obtained after aspiration shows that the size of the collection is markedly decreased, with a residual hypoechoic area of inflammation. The patient was prescribed cloxacillin for a total of 10 days and instructed to return for reevaluation. Follow-up US peformed 14 days later showed clinical improvement of the abscess. Cultures showed growth of S aureus sensitive to cloxacillin 54


US image obtained after aspiration shows that the size of the collection is markedly decreased, with a residual hypoechoic area of inflammation. The patient was prescribed cloxacillin for a total of 10 days and instructed to return for reevaluation. Follow-up US peformed 14 days later showed clinical improvement of the abscess. Cultures showed growth of S aureus sensitive to cloxacillin.Repeat US image obtained in a now asymptomatic patient 6 weeks after initial presentation shows hardly discernible US abnormalities.

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Central nonpuerperal abscess in a 17-year-old smoker with nipple retraction and a palpable central mass in the right breast. There were no associated inflammatory signs. (a) US image shows a heterogeneous 37-mL collection with posterior enhancement. Percutaneous drainage with an 18-gauge needle yielded 35 mL of purulent material, which was sent for culture. The patient was prescribed clindamycin empirically for 10 days and instructed to return for evaluation in 1 week 56


US image obtained 1 week later shows a smaller 18-mL cavity, which represents slight improvement. However, there are more internal echoes, a finding suggestive of thick material. Repeat aspiration was performed and yielded 15 mL of fluid. Cultures from the first culture series showed growth of Staphylococcus that was resistant to clindamycin. The patient was prescribed a course of cloxacillin and instructed to return 1 week later. 57


US image obtained 1 week later shows a 5-mL residual collection, which represents significant improvement. Repeat aspiration yielded 4 mL of pus, and continued antibiotics were prescribed. At evaluation 3 weeks later, clinical symptoms had disappeared.

US image obtained 3 weeks later shows a residual irregular hypoechoic zone. Because of the unusual clinical presentation, core biopsy was performed. Pathologic analysis demonstrated marked chronic inflammation without any signs of atypia or neoplasia. The further clinical course was favorable58


Bilateral recurring periareolar abscesses in a 25-year-old woman who noted an area of redness and swelling in the right breast with spontaneous pus drainage from a fistulous tract 1 day earlier. There was no associated fever. A 500-mg dose of cephalexin twice a day was prescribed for 10 days. (a) US image shows a hypoechoic irregular collection in the periareolar region. Although the sonographic appearance was suggestive of thick fluid, aspiration was attempted. (b) US image shows aspiration with an 18-gauge needle, which yielded 4 mL of thick, slightly bloody material that was 59


US image shows aspiration with an 18-gauge needle, which yielded 4 mL of thick, slightly bloody material that was sent for culture. The collection decreased in size. No microorganisms were identified in the cultures. Three months later, because of continued symptoms, the patient consulted a surgeon and an incision and drainage procedure were performed. One year later, the patient experienced a new infectious episode, which this time affected the left periareolar region. Cloxacillin was initially prescribed; radiologic evaluation was peformed 4 weeks later because symptoms persisted. (c) US image shows an ill-defined multiloculated collection. 60


US image shows drainage with an 18-gauge catheter. Less than 2 mL of material was obtained; again, cultures sent for microbiologic analysis were sterile. A repeat course of an antibiotic (clindamycin) was nonetheless prescribed for 10 days, with the thought that the cultures may have been falsely negative due to previous antibiotic treatment. Because of a new fistula tract that occurred 4 weeks later, the patient underwent surgical incision and drainage in the operating room to treat the recurrent left breast abscess61


Central nonpuerperal abscess in a 36-year-old woman with periareolar redness and a palpable painful mass in the right breast at the 1-oclock position. The patient was a smoker who had undergone surgery twice before for recurrent left breast subareolar abscesses. The patients mother had been diagnosed with breast cancer at 49 years of age. (a) US image shows an ill-defined heterogeneous collection, from which 5 mL of thick greenish purulent material was drained under US guidance. Cultures showed growth of mixed anaerobes, predominantly Bacteroides and Fusobacterium. The patient was treated with clindamycin for 10 days. (b) Follow-up US image obtained 1 month later shows complete resolution of the collection 62


Peripheral nonpuerperal abscess in a 37-year-old woman with a painful, progressive, palpable mass in the upper inner quadrant of the left breast. No skin redness or other signs of infection were found. Clinically, the treating physician suspected a cyst and referred the patient to an outside clinic for US evaluation. (a) Color Doppler image shows an ill-defined heterogeneous lesion with increased vascularity in the periphery and a small hypoechoic center. The lesion was interpreted as suspicious for malignancy 63


(c) On a US image, the lesion appears enlarged and more clearly liquid in the center. The possibility of an infectious lesion was considered. US-guided drainage yielded 4 mL of yellowish thick purulent material. Fine-needle aspiration of the cortex of the enlarged lymph node was also performed but revealed only inflammatory changes. The patient was prescribed cloxacillin for 7 days and instructed to return 2 weeks later. (d) Follow-up US image obtained 3 weeks later shows decreased size of the collection. Repeat aspiration yielded less than 1 mL of thick material. A second course of antibiotics was prescribed after cultures showed growth of clindamycin-sensitive S aureus. 64


Peripheral nonpuerperal abscess in a 22-year-old woman with a palpable progressive mass in the upper outer quadrant of the right breast. There was no associated redness or pain. The patient was a smoker, had undergone bilateral nipple piercing 3 months earlier, and was the mother of a 2-year-old child. (a) Initial US image shows a large (65-mL), heterogeneous, mostly hypoechoic, irregular lesion. The possibilities of a complex cyst or galactocele were considered. Because of the heterogeneous texture, the radiologist thought that a solid component could not be ruled out with US alone and that aspiration was required. US-guided aspiration was performed with a 14-gauge needle. A total of 10 mL of pus was retrieved, after which lavage of the residual collection was performed three times with normal saline. The patient was prescribed cloxacillin for 10 days. Follow-up US was performed 6 days later because of lack of clinical improvement. Cultures showed growth of Streptococcus and mixed anaerobes, mostly Fusobacterium and Peptostreptococcus. Clindamycin was prescribed. (b) US image shows that the collection has reaccumulated since the first aspiration attempt. Repeat aspiration was attempted and yielded 15 mL of brownish thick material. The patient was instructed to return in 4 days for reevaluation. 65


US image obtained 4 days later shows that the collection has further increased in size. A decision was made to insert a drain. An 8-F catheter from Cook (Bloomington, Ind) allowed immediate drainage of 60 mL of thick material. Clinical follow-up revealed decreased drainage from the catheter after a few days. (d) Repeat US image shows a slightly smaller abscess with numerous internal echoes. A decision was made to remove the catheter 6 days after insertion. Antibiotic therapy was continued. The clinical course required surgical incision and drainage, with placement of a mesh that remained in place for 3 weeks. (e) (no la puse) Follow-up US image obtained 2 months later shows a small residual area of hypoechoic texture, which represents significant improvement. This area eventually resolved fully66

ABSCESO MAMARIO.Tratamiento antibitico:

Siempre debe ser ofrecido en adicin al drenaje percutneo.Buena opcin de primera lnea incluye 500mg de cloxacilinia administrada va oral, cada seis horas por 7 a 10 das.Alternativas:Clindamicina 300mg cada seis horas 7 a 10 das.Eritromicina 500mg cada ocho horas o cefazolina 500mg cada seis horas va oral por 7 a 10 das. Alguno autores sugieren agregar 500mg de metronidazol cada ocho horas (mujer no purpera).


After aspiration, the material obtained should always be sent for microbiologic analysis, where the pathogen can be identified and its antibiotic, sensitivity profile determined to allow subsequent antibiotic adjustment, if necessary. When the clinical scenario suggests a greater risk of recurrence, for example when dealing with nonpuerperal central abscesses, broader-spectrum antibiotics can be prescribed from the onset.67

ABSCESO MAMARIO.Tratamiento: En los ltimos 15 aos la intervencin guiada por US ha sido el abordaje preferido.Debiendo ser ejecutado rpidamente, con anestesia local, en pacientes ambulatorios, con mnimo dao, sin la necesidad de interrumpir la lactancia y con un rango de complicacin mas bajo o similar que el drenaje quirrgico.Trop I, et al. Breast Abscesses: Evidnece-based Algorithms for diagnosis, Manegment and Follow-up. Radiographics 2011;6:1683-1699.

When Is Surgery Indicated?A small minority of women will ultimately be referred for surgical treatment. The more recent articles describing the treatment of breast abscesses suggest referring women for surgical drainage after failure of several attempts (at least three to five) at US-guided drainage, although management decisions depend on the clinical context (13). Multiloculated and larger abscesses (the most common size cutoff is 3 cm) are more difficult to treat and associated with an approximately 50% rate of failure to cure with aspiration 68




Conclusiones.Mastalgia cclica y no cclica.Galactocele.Mastitis puerperal y no puerperal.Absceso mamario.

Mastodinia, galactocele, mastitis y absceso mamario.

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Transcript of Mastodinia, galactocele, mastitis y absceso mamario.