Public Comment

Individuals making comments must provide their name, institution/affiliation, and email address. This is for internal use only. We appreciate you taking the time to read the benign breast disease guidelines and provide your feedback. We will review and consider all comments, but retain ultimate discretion regarding the final content of the clinical consensus statement.

Instructions
Please use the form below to enter your comments. Once you have provided all of your comments, please remember to click the “Submit” button. This page should not expire due to inactivity.

The deadline to submit comments is October 31, 2024.

Please contact Laura Randel (lrandel@breastsurgeons.org) if you have any questions.

Question Title

* Name

Question Title

* Institution/Organization

Methodology
Strong Consensus If >90% of panelist rate a recommendation as either “strongly agree” or “agree” and the median score is 1
Consensus If > 75% and <90% of panelists rate a recommendation as either “strongly agree” or “agree” and the median is either 2 or 1
No Consensus any other rating scores



1. Initial Management

Question Title

* 1a. All patients with PDM-SMOLD who have pierced nipples should be counseled to remove the jewelry. (Strong Consensus)

Question Title

* 1b. Patients with cleft nipples and PDM-SMOLD should be counseled to try to keep the depths of the crevice dry and free from debris. (Strong Consensus)

Question Title

* 1c. When patients with a first episode of PDM-SMOLD have erythema or an abscess, antibiotics should be started. Antibiotic coverage should include Staphylococcus (and possibly methicillin resistant Staph aureus). (Strong Consensus)

Question Title

* 1d. Cultures should be obtained when pus is present in PDM-SMOLD, preferably before antibiotics are initiated. Antibiotics should be prescribed or adjusted according to the results of the culture. (Strong Consensus)

Question Title

* 1e. When patients’ clinical and imaging findings are not typical for PDM-SMOLD or findings do not resolve after treatment, a core biopsy should be performed to rule out a malignancy. (Strong Consensus)

2.Percutaneous Interventions

Question Title

* 2a. For patients with PDM-SMOLD and a subareolar breast abscess, an ultrasound-guided aspiration and culture of the aspirated contents should be performed. (Strong Consensus)

3. Imaging

Question Title

* 3a. An ultrasound should be performed for all patients initially presenting with PDM-SMOLD. (Strong Consensus)

Question Title

* 3b. If a patient with PDM-SMOLD does not improve with an initial course of antibiotics, a repeat ultrasound should be obtained. (Strong Consensus)

Question Title

* 3c. A mammogram should be considered for patients with PDM-SMOLD who are 30 years of age or over and have discordant ultrasound findings or who fail to respond to treatment. (Strong Consensus)

Question Title

* 3d. When available, ultrasound guidance for aspirations of fluid collections for PDM-SMOLD should be utilized. (Strong Consensus)

4. Indications for Surgery

Question Title

* 4a. Clinicians should perform an incision and drainage procedure for patients with PDM-SMOLD with breast abscesses that persist after several aspirations and those with thin, attenuated overlying skin. (Strong Consensus)

Question Title

* 4b. Clinicians should consider operative excision for a patient with PDM-SMOLD who has a fistula that persists after the initial episode. (Strong Consensus)

Question Title

* 4c. Patients with an asymptomatic, congenital cleft nipple who are not undergoing operation as treatment for PDM-SMOLD do not require surgery to correct the cleft nipple. (Strong Consensus)

Question Title

* 4d. Clinicians should perform definitive operations for PDM-SMOLD during a quiescent period when acute inflammation and infection have resolved.(Strong Consensus)

Question Title

* 4e. Clinicians should counsel patients that smoking cessation is encouraged, but not required to undergo an operation for PDM-SMOLD. (Strong Consensus)

Question Title

* 4f. Clinicians should consider surgery for recurrent episodes of PDM-SMOLD. (Consensus)

5. Performance of the Surgical Procedure

Question Title

* 5a. The ducts in the central core of the nipple, the underlying sinus and scarring, and the fistula tract, if present, should generally be removed using a radial elliptical incision, although a circumareolar incision is another option for patients with PDM-SMOLD. (Consensus)

Question Title

* 5b. If a cleft or inverted nipple is present in a patient undergoing surgery for PDM-SMOLD, clinicians should correct the cleft or inverted nipple at the time of the definitive operation. (Consensus)

Question Title

* 5c. For patients who have had multiple unsuccessful operations for PDM-SMOLD and have severe deformity, clinicians should consider performing excision of the diseased tissue in conjunction with glandular remodeling or local flap rotation. (Strong Consensus)

6. Other non-Surgical Management

Question Title

* 6a. Clinicians should not recommend breast duct irrigation as first line therapy for patients with PDM-SMOLD. (Strong Consensus)

Question Title

* 6b. For patients with recurrent abscesses associated with PDM-SMOLD, clinicians should prescribe antibiotics that cover mixed flora, especially anaerobes. (Strong Consensus)

7. Follow-up Care

Question Title

* 7a. Although routine follow-up is not necessary for patients with PDM-SMOLD, clinicians should advise patients to return promptly if symptoms recur. (Strong Consensus)

Question Title

* 7b. Clinicians should counsel patients with PDM-SMOLD to stop smoking. (Strong Consensus)

Appendix 2. Literature Search Results

A review of the literature was conducted in support of development of these pathway recommendations. Search parameters and resulting references are below.  

Search Parameters:
(breast abscess) OR (zuska's disease) OR (Lactiferous duct fistula) OR (SMOLD)

Filters applied: Clinical Trial, Controlled Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Systematic Review, in the last 10 years, Humans, English.

1. Crepinsek MA(1), Taylor EA(2), Michener K(3), Stewart F(4). Interventions for preventing mastitis after childbirth.Cochrane Database Syst Rev. 2020 Sep 29;9(9):CD007239. doi: 10.1002/14651858.CD007239.pub4.

2. Mangesi L(1), Zakarija-Grkovic I. Treatments for breast engorgement during lactation.Cochrane Database Syst Rev. 2016 Jun 28;2016(6):CD006946. doi: 10.1002/14651858.CD006946.pub3.

3. McCrossan S(1), Martin S(2), Hill C(2). Medical Tourism in Aesthetic Breast Surgery: A Systematic Review. Aesthetic Plast Surg. 2021 Aug;45(4):1895-1909. doi: 10.1007/s00266-021-02251-1. Epub 2021 Apr 19.

4. Buttgereit F(1), Aelion J(2), Rojkovich B(3), Zubrzycka-Sienkiewicz A(4), Chen S(5), Yang Y(5), Arikan D(5), D'Cunha R(5), Pang Y(5), Kupper H(6), Radstake T(5), Amital H(7). Efficacy and Safety of ABBV-3373, a Novel Anti-Tumor Necrosis Factor Glucocorticoid Receptor Modulator Antibody-Drug Conjugate, in Adults with Moderate-to-Severe Rheumatoid Arthritis Despite Methotrexate Therapy: A Randomized, Double-Blind, Active-Controlled Proof-of-Concept Phase IIa Trial. Arthritis Rheumatol. 2023 Jun;75(6):879-889. doi: 10.1002/art.42415. Epub 2023 Apr 2.

5. Ghalleb M(1)(2), Seghaier S(3)(4), Adouni O(5)(4), Bouaziz H(3)(4), Bouida A(3)(4), Hassouna JB(3)(4), Chargui R(3)(4), Rahal K(3)(4). Breast tuberculosis: a case series. J Med Case Rep. 2021 Feb 20;15(1):73. doi: 10.1186/s13256-020-02646-9.

6. Irusen H(1), Rohwer AC, Steyn DW, Young T. Treatments for breast abscesses in breastfeeding women. Cochrane Database Syst Rev. 2015 Aug 17;2015(8):CD010490. doi: 10.1002/14651858.CD010490.pub2.

7. Wang YC(1), Szatmary P(1), Zhu JQ(1), Xiong JJ(1), Huang W(1), Gomatos I(1), Nunes QM(1), Sutton R(1), Liu XB(1). Prophylactic intra-peritoneal drain placement following pancreaticoduodenectomy: a systematic review and meta-analysis. World J Gastroenterol. 2015 Feb 28;21(8):2510-21. doi: 10.3748/wjg.v21.i8.2510.

8. Togo A(1)(2), Dufour JC(3), Lagier JC(1)(2), Dubourg G(1)(2), Raoult D(1)(2), Million M(1)(2). Repertoire of human breast and milk microbiota: a systematic review. Future Microbiol. 2019 May;14:623-641. doi: 10.2217/fmb-2018-0317. Epub 2019 Apr 26.

9. Yu MC(1), Feng YJ(2), Wang W(2), Fan W(2), Cheng HT(2), Xu J(2). Is laparoscopic appendectomy feasible for complicated appendicitis ? A systematic review and meta-analysis. Int J Surg. 2017 Apr;40:187-197. doi: 10.1016/j.ijsu.2017.03.022. Epub 2017 Mar 14.

10. Zhou F(1)(2), Li Z(1)(2), Liu L(1)(2), Wang F(1)(2), Yu L(1)(2), Xiang Y(1)(2), Zheng C(1)(2), Huang S(1)(2), Yu Z(1)(2). The effectiveness of needle aspiration versus traditional incision and drainage in the treatment of breast abscess: a meta-analysis. Ann Med. 2023 Dec;55(1):2224045. doi: 10.1080/07853890.2023.2224045.

11. Zhang Y(1), Gao Y(2), Qin J(1), Li X(3), Jiang F(4), Cai Y(5), Feng H(6), Gu X(7), Gao M(8), Wang L(9), Lin Y(10), Fan Y(11), Xu B(12), Wang E(13), Shao Q(14). Breast microecology improvement using probiotics following needle aspiration in patients with lactational breast abscess: a multi-center randomized double-blind controlled trial. Sci Rep. 2022 Oct 6;12(1):16692. doi: 10.1038/s41598-022-20756-w.

12. Samson DJ(1), Gachabayov M(2), Latifi R(3)(4). Biologic Mesh in Surgery: A Comprehensive Review and Meta-Analysis of Selected Outcomes in 51 Studies and 6079 Patients. World J S
13. Kinj R(1), Chand ME(1), Gal J(2), Gautier M(1), Montagné L(1), Lam Cham Kee D(1), Hannoun-Lévi JM(3). Single fraction of accelerated partial breast irradiation in the elderly: early clinical outcome. Radiat Oncol. 2018 Sep 12;13(1):174. doi: 10.1186/s13014-018-1119-6.

14. Li C(1), Liu Y(2), Jiang Y(3), Xu Y(4), Wang Z(5). Single-incision compared with conventional laparoscopy for appendectomy in acute appendicitis: a systematic review and meta-analysis. Int J Colorectal Dis. 2022 Sep;37(9):1925-1935. doi: 10.1007/s00384-022-04231-6. Epub 2022 Aug 8.

15. Yu NZ, Huang JZ, Zhang H, Wang Y, Wang XJ, Zhao R, Bai M, Long X(1). A systemic review of autologous fat grafting survival rate and related severe complications. Chin Med J (Engl). 2015 May 5;128(9):1245-51. doi: 10.4103/0366-6999.156142.

16. Zhang Y(1), Gao Y, He X, Ding S, Gao H. Oral Lactobacillus fermentum CECT5716 in the patients with lactational abscess treated by needle aspiration: The late follow-up of a randomized controlled trial. Medicine (Baltimore). 2022 Jul 1;101(26):e29761. doi: 10.1097/MD.0000000000029761.

17. Giguère GB(1), Poirier B(1), Provencher L(1), Boudreau D(1), Leblanc D(1), Poirier É(1), Hogue JC(1), Morin C(1), Desbiens C(2). Do Preoperative Prophylactic Antibiotics Reduce Surgical Site Infection Following Wire-Localized Lumpectomy? A Single-Blind Randomized Clinical Trial. Ann Surg Oncol. 2022 Apr;29(4):2202-2208. doi: 10.1245/s10434-021-11031-9. Epub 2021 Nov 25.

18. Yashar C(1), Khan AJ(2), Chen P(3), Einck J(4), Poppe M(5), Li L(3), Yehia ZA(6), Vicini FA(7), Moore D(6), Arthur D(8), Quinn TJ(3), Kowzun M(6), Simon L(9), Scanderbeg D(9), Shah C(10), Haffty BG(6), Kuske R(11). Three-Fraction Accelerated Partial Breast Irradiation (APBI) Delivered With Interstitial Brachytherapy Is Safe: First Results From the Tri-fraction Radiation Therapy Used to Minimize Patient Hospital Trips (TRIUMPH-T) Trial. Pract Radiat Oncol. 2023 Jul-Aug;13(4):314-320. doi: 10.1016/j.prro.2023.03.006. Epub 2023 May 1.

19. Zhang X(1), Lin Y(1), Sun Q(2), Huang H(3). Dermo-glandular flap for treatment of recurrent periductal mastitis. J Surg Res. 2015 Feb;193(2):738-44. doi: 10.1016/j.jss.2014.07.067. Epub 2014 Aug 6.

20. Gerber B(1), von Minckwitz G, Eidtmann H, Rezai M, Fasching P, Tesch H, Eggemann H, Schrader I, Kittel K, Hanusch C, Solbach C, Jackisch C, Kunz G, Blohmer JU, Huober J, Hauschild M, Nekljudova V, Loibl S, Untch M. Surgical outcome after neoadjuvant chemotherapy and bevacizumab: results from the GeparQuinto study (GBG 44). Ann Surg Oncol. 2014 Aug;21(8):2517-24. doi: 10.1245/s10434-014-3606-9. Epub 2014 Apr 18.

21. Gong JP(1), Yang L, Huang XE, Sun BC, Zhou JN, Yu DS, Zhou X, Li DZ, Guan X, Wang DF. Outcomes based on risk assessment of anastomotic leakage after rectal cancer surgery. Asian Pac J Cancer Prev. 2014;15(2):707-12. doi: 10.7314/apjcp.2014.15.2.707.

22. Liu PZ(1), Shi XG(2), Zuo XM(1), Lai R(1), Zhao Z(1), Yang ZR(1), Liu JL(1). A clinical study on the treatment of granulomatous lobular mastitis by the external application of the internal pus-expelling decoction and operation. Ann Palliat Med. 2020 Sep;9(5):2631-2641. doi: 10.21037/apm-19-684. Epub 2020 Aug 25.

23. Lei P(1), Ruan Y(2), Yang X(1), Fang J(1), Chen T(3). Trans-anal or trans-abdominal total mesorectal excision? A systematic review and meta-analysis of recent comparative studies on perioperative outcomes and pathological result. Int J Surg. 2018 Dec;60:113-119. doi: 10.1016/j.ijsu.2018.11.003. Epub 2018 Nov 9
24. Mortimer J(1), Jung J, Yuan Y, Kruper L, Stewart D, Chung S, Yu KW, Mendelsohn M, D'Apuzzo M, Tegtmeier B, Dadwal S. Skin/nail infections with the addition of pertuzumab to trastuzumab-based chemotherapy. Breast Cancer Res Treat. 2014 Dec;148(3):563-70. doi: 10.1007/s10549-014-3190-5. Epub 2014 Nov 11.

25. de Oliveira ASLE(1), Bloise G(2)(3), Moltrasio C(4)(5), Coelho A(3), Agrelli A(6), Moura R(7), Tricarico PM(7), Jamain S(8), Marzano AV(4)(9), Crovella S(10), Cavalcanti Brandão LA(2). Transcriptome Meta-Analysis Confirms the Hidradenitis Suppurativa Pathogenic Triad: Upregulated Inflammation, Altered Epithelial Organization, and Dysregulated Metabolic Signaling. Biomolecules. 2022 Sep 25;12(10):1371. doi: 10.3390/biom12101371.

26. Spring MA(1). Use of a Lysine-Derived Urethane Surgical Adhesive as an Alternative to Progressive Tension Sutures in Abdominoplasty Patients: A Cohort Study. Aesthet Surg J. 2018 Nov 12;38(12):1318-1329. doi: 10.1093/asj/sjy094.

Question Title

* Please indicate in the box any general comments or global suggestions on the entire document.

T