Teaching Case

The patient was a 39-year-old woman, with unilateral and uniorificial galactorrhoea in the right breast. Neither fever, palpable lesions nor inflammatory signs were present in the breasts. We performed cytology of the galactorrhoea.

Initially we performed a mammography, breast-US and galactography. The mammography (craneocaudal and oblique projections) (Fig. 1 and Fig. 2) and US (Fig. 3) did not show anything pathological. The galactography of the right breast (Fig. 4) revealed a stop defect in the conduct of the canalized nipple. Intraductal papiloma was our first diagnosis. We made the MRI and found bilateral subareolar nodules in T1weighted + Gadolinium with fat suppression (Fig. 5). Those lesions were round fluid-filled cavities without enhancement and a peripheral capsule with an intense enhancement. Moreover, the surrounding inflammatory tissue had a moderated enhancement. The findings were compatible with bilateral subareolar abscesses, and those were confirmed with the cytology. Finally, we repeated a reassessment US and the patient indicated that the galactorrhoea was actually bilateral. The second US findings (Fig. 6) were bilateral subareolar and hypoechoic nodules with anechoic centres, compatible with abscesses.

The breast abscesses can be secondary to a chronic or acute mastitis, extension from a local infection (Montgomery glands, sweat glands), pleural or chest wall abscess. The pathogen can be bacteria, tuberculosis, fungi or parasites.
Histology: Is a round cavity of pus, uni or multilobulated, surrounded by a capsule of granulation tissue, inflammatory cells and fibroblasts. Usually it presents an external oedema and may fistulize.
Clinical findings: fever, palpable and fluctuate nodule and inflammatory changes on the skin.

Mammography findings: Round nodule, space-occupying lesion. Ill-defined outline because of the surrounding oedema, occasionally with air collection or air-fluid levels inside.
US findings: (it is the method of choice to evaluate a breast abscess) Hypoechoic, round or oval lesion, the outline is smooth or irregular, can be surrounded by oedema. In mature abscess we can find internal echoes, thin septation or gas bubbles. The sonography is useful for percutaneous drainage.
Enhanced MRI findings: Round or oval cavities, fluid-filled without enhancement and variable intensity, a periphery capsule with an intense and early enhancement. This lesion is surrounded by inflammatory tissue with a moderated and delayed enhancement.
Generally, abscesses are more common in lactating women. In non-puerperal women, it is possible to divide the abscess into two groups: Central/subareolar abscesses, more frequent in young smoker women. Peripheral abscesses, more frequent in old women with systemic disease.
In the clinical condition of Zuska disease appears as recurrent bilateral breast abscesses and fistulae, in non-puerperal women.