Mastitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2] Shadan Mehraban, M.D.[3]

Overview

Mastitis must be differentiated from other diseases that cause breast pain and/or swelling, such as galactocele[1][2], breast engorgement[3][4] [5], mastodynia[6][7][8], fibrocystic breast disease, breast cancer, fibroadenoma, mondor's disease[9][10] and breast abscess.

Differentiating Mastitis from other diseases

Mastitis must be differentiated from other diseases that cause breast pain and swelling as shown below:[11][12] [13][14][15][16][17][10][18][19]

Diseases Laboratory Findings Physical Examination History and Symptoms Other Findings
Culture of the discharge Biopsy Breast tenderness Skin induration Cordlike vein appearance History of trauma Nipple retraction Nipple discharge Erythema Fever Warmth Lymphadenopathy Itching
Breast abscess + - + + - + - + + + + - -
Mastitis + - + - + - + + + + + -
Inflammatory breast cancer - + + + - + - + - + + + *Peau d' orange appearance of the skin

*Metastasis is common.

Galactocele - - - - - - + - - - - - It is differentiated from other masses by US.
Mondor's syndrome + + + - Retracted breast skin and elevation of the skin may be observed.
Cellulitis - + + + - + + -
Fibroadenoma - + - - - - + *Peau d' orange skin apperance.

*Enlarged veins on the skin

Other differential diagnosis of mastitis may include:

ABBREVIATIONS
LAP=Lymphadenopathy, HRT=Hormonal replacement therapy, FNA=Fine needle aspiration, DCIS=Ductal carcinoma in-situ

Diseases Benign or

Malignant

Clinical manifestation Paraclinical findings Gold standard diagnosis
Demography History Symptoms Signs Histopathology Imaging
Mass Mastalgia Nipple discharge Breast exam Skin changes LAP
Fibroadenoma[20] + ±
  • Solitary
  • Well-defined
  • Mobile mass
Ultrasound:
  • Well-defined
  • Solid mass
Breast cyst[21]
  • May resolve after aspiration
  • Further evaluation for unresolved masses
+ ±
  • Solitary
  • Cluster of small masses or an ill-defined mass
  • Smooth, firm, and frequently tender
  • Nonproliferative breast lesions
Ultrasound:
  • Simple cyst: Well circumscribed, posterior acoustic enhancement without internal echoes
  • Complicated cyst: Homogenous low-level internal echoes due to without solid components
  • Complex cyst: Thick walls greater than 0.5 mm with solid component
Fibrocystic change[22]
  • Unknown prevalence among adolescents
  • >50% in women of reproductive age
+ + ±
  • Nonproliferative breast lesions
Ultrasound:
  • Small cysts in mammary zone
  • Fibroglandular tissue around the mass
Galactocele[23][24] + ± ± Mammography:
  • Intermediate mass in absence of classic fat-fluid level

Ultrasound:

  • Complex mass
Cysts of montgomery[25]
  • Most common in age of 10-20 years old
  • More than 80% resolve spontaneously
  • Drainage is essential in rare cases
+ ± ±
  • Asymptomatic subareolar mass
  • Drainage of clear to brownish fluid
± Ultrasound:
  • Single cystic lesion in retroareolar area
Hamartoma[26]
  • Common in women older than 35 years old
± ± Mammography:
  • Well-described
  • Discrete, solid, and encapsulated lesion
Breast abscess[27][28]
  • Complication of lactational mastitis in 14% of cases
  • Common among African-American women, heavy smokers , and obese patients
+ + + Ultrasound:
  • Fluid collection
Mastitis[29][30] ± + ± + Breast parenchyma inflammation: Ultrasound:
  • Ill-defined area with hyperechogenicity with inflamed fat lobules
  • Skin thickening
Diseases Benign or
Malignant
Demography History Mass Mastalgia Nipple discharge Breast exam Skin changes LAP Histopathology Imaging Gold standard diagnosis
Breast carcinoma[31][32][33]
  • Most common diagnosed cancer among women
  • Leading cause of cancer death in women 40-49 years old
+ ±
  • Hard
  • Immobile
  • Solitary
  • Irregular margin
± ± Mammography:

Ultrasound:

Ductal carcinoma in situ (DCIS)[34][35] ± ±
  • May have normal physical exam
Mammography:
Microinvasive breast cancer[36]
  • Rare
  • Commonly referred to DCIS with microinvasion
  • Average age 50-60 years old
+ ±
  • Solitary
  • Firm palpable mass
±
  • Associated with high grade DCIS
Mammography:
Breast sarcoma[37]
  • Rare type, < 1% of all breast malignancies
  • Average age of between 45-50 years
+
  • Well-defined
  • Firm mass
± Mammography:
  • Noncalcified oval mass Indistinct margins
Phyllodes tumor[38][39] ±
  • Smooth and multinodular
  • Well-defined
  • Firm mass
  • Mobile
  • Nonepithelial breast neoplasm with average size of 5 cm
Ultrasound:
  • Solid mass
  • Hypoechoic
  • Well-circumscribed

Mammography:

  • Smooth mass
  • Polylobulated mass
Lymphoma[40][41]
  • Extremely rare ( 0.04%-0.5%)
  • Average age 55-60 years
+
  • Well-defined, firm mass
  • Multiple
± Mammography:
Duct ectasia[42]
  • Usually resolve spontaneously
± ± ±
  • Usually asymptomatic
  • Distention of subareolar ducts
Ultrasound:
  • Dilated milk ducts
  • Fluid-filled ducts
Intraductal papilloma[43]
  • Common in women between 35-55 years old
+ ± ±
  • Solitary or multiple lesion
  • Large lump near nipple
  • Growth of papillary cell into a lumen
Ultrasound:
  • Well-defined
  • Solid nodule
Lipoma[44]
  • Common between age of 40-60 years old
  • Benign tumors
  • May experience recurrence
+
  • Solitary
  • Mobile
  • Soft mass
Ultrasound:
  • Well-Circumscribed
  • Hypoechoic lesion
Sclerosing adenosis[45][46]
  • Recurrent pain during mensturation
  • May present as a mass or incidental finding on mammogram
  • No treatment is needed
± +
  • Multiple lesion
  • Firm
  • Tender nodules
±
  • Proliferative disease
Mammography:
Pseudoangiomatous stromal hyperplasia[47][48]
  • Common in reproductive age women
+
  • Solitary firm mass
  • Thickening
Mammography and ultrasound:
  • Well-defined
  • Solid mass
  • Noncalcified
Mondor's disease[49][50]
  • Benign and self-limiting disease
  • Resolve after 4-6 weeks
+ +
  • Thick and tender cord on breast skin
+
  • N/A
Ultrasound:
  • Tubular anechoic structure
  • Multiple narrowing areas
Diseases Benign or
Malignant
Demography History Mass Mastalgia Nipple discharge Breast exam Skin changes LAP Histopathology Imaging Gold standard diagnosis
Diabetic mastopathy[51]
  • Suspicious breast mass
  • After diagnosis, excision is not required
+
  • Ill-defined mass
  • Immobile
Ultrasound:
  • Irregular mass
  • Hypoechoic
  • Dense lesion
Gynecomastia[52][53]
  • Benign breast tissue swelling among men and boys around puberty
+ ± ±
  • Unilateral or bilateral firm mass
  • Breast swelling
  • Rubbery mass
Ultrasound:
Sarcoidosis[54]
  • Rare in patients with systemic involvement
+
  • Firm mass
  • Hard mass
Mammography:
  • Irregular
  • Ill-defined
  • Spiculated solid mass
Fat necrosis[55] + ±
  • Hard or smooth mass
  • Solitary mass
  • Mobile
  • Collections of liquefied fat
Ultrasound:
  • Collections of liquefied fat
  • Oil cysts

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