Male breast cancer is rare with an incidence of 1.2 in 100 000.1
Breast malignancy presenting as an abscess is also a very rare phenomena. The combination of both a male breast cancer and an unusual presentation as an abscess make this a very distinctive case. Literature review reveals only a case series of eight female patients with adenocarcinoma presenting as an abscess.2
Several cases were also reported of primary squamous cell carcinoma presenting as a breast abscess in women.3–8
Given its rarity, it has been suggested that a malignancy when associated with an overlying breast abscess is coincidental, and, therefore, it is not necessary to always biopsy the cavity wall.9
Over recent years, there has been a trend towards minimally invasive methods of breast-abscess drainage. Ultrasound-guided drainage has become the first-line treatment in many centres, and recently vacuum-assisted core-biopsy devices (mammotome) have been advocated.9 10
Percutaneous therapies have been shown to be effective treatment for the abscess itself,9
but do not obtain tissue for histological examination. Fine-needle aspiration (FNA) and cytology is often useful in diagnosis of diseases of the breast; however, the difficulty in distinguishing between well-differentiated tumours, tumours with necrosis and inflammation, and those changes seen in a breast abscess make it less useful.4
Scott and his colleagues in 20062
set out to address the issue of whether the rate of breast cancers occurring in breast abscesses warranted biopsying all abscesses, and therefore, whether percutaneous drainage without biopsy was a safe and valid method.
They found that 9 of 206 patients (4.3%) were diagnosed with malignancy in cavity-wall tissue. They concluded that malignancy presenting as an abscess was a suitably rare finding and that, in such cases, ultrasound-directed aspiration without biopsy should be the first-line therapy. The ongoing argument is that performing biopsy on all abscesses would place an unnecessary burden on histopathology services, given the low yield of malignancies. All of the published cases in the literature of malignancies related to an abscess have been described in women aged more than 40 years,3–8
an exception being an angiolipoma presenting as a breast abscess in a 21-year-old woman.2
- We agree that malignancy underlying a breast abscess is a rare occurrence and first-line management should be percutaneous treatment. However, the lesson learnt from this case stresses the importance of obtaining cavity-wall tissue for histology on any chronic, non-resolving breast abscess. To ensure complete resolution of breast abscesses adequate follow-up should be provided.
- We feel that rather than biopsying all abscesses, a more focused strategy may be more appropriate. This could involve obtaining a cavity-wall specimen in all abscesses not resolving within 2 months after initial percutaneous management. This histology can be obtained by ultrasound guided FNA, core or vacuum-assisted biopsy or by formal incision and drainage.