Wo m e n ’s I m a g i n g • R ev i ew

Kasales et al.
Mastitis and Subareolar Abscess

Women’s Imaging
Review

FOCUS ON:

Nonpuerperal Mastitis and

Subareolar Abscess of the Breast
Claudia J. Kasales1 OBJECTIVE. The purpose of this article is to show radiologists how to readily recog-
Bing Han2 nize nonpuerperal subareolar abscess and its complications in order to help reduce the time
J. Stanley Smith, Jr 3 to definitive therapy and improve patient care. To achieve this purpose, the various theories
Alison L. Chetlen1 of pathogenesis and the associated histopathologic features are reviewed; the typical clinical
Heather J. Kaneda1 characteristics are detailed in contrast to those seen in lactational abscess and inflammatory
breast cancer; the common imaging findings are described with emphasis on the sonograph-
Serene Shereef 3
American Journal of Roentgenology 2014.202:W133-W139.

Kasales CJ, Han B, Smith JS Jr, Chetlen AL,
Kaneda HJ, Shereef S
ic features; correlative pathologic findings are presented to reinforce the imaging findings as
they pertain to disease origins; and the various treatment options are reviewed.
CONCLUSION. Nonpuerperal subareolar mastitis and abscess is a benign breast entity
often associated with prolonged morbidity. Through better understanding of the underlying
disease process the imaging, physical, and clinical findings of this rare process can be more
readily recognized and treatment options expedited, improving patient care.

Keywords: breast abscess, inflammatory breast cancer,
mastitis, nonlactational, nonpuerperal, subareolar
DOI:10.2214/AJR.13.10551
Received January 6, 2013; accepted after revision
April 16, 2013.
1
Department of Radiology, Penn State Milton S. Hershey
Medical Center, PO Box 850, Hershey, PA 17033. Address
correspondence to C. J. Kasales (ckasales@hmc.psu.edu).
2
Division of Anatomic Pathology, Penn State Milton S.
Hershey Medical Center, Hershey, PA.
3
Department of Surgery, Penn State Milton S. Hershey
Medical Center, Hershey, PA.
This article is available for credit.
WEB
This is a web exclusive article.
AJR 2014; 202:W133–W139
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© American Roentgen Ray Society
N
onpuerperal subareolar mastitis
and abscess, also known as Zuska
disease, is a relatively uncommon
benign breast entity, representing
1–2% of all symptomatic breast processes [1].
Despite being benign, it is an important source
of prolonged morbidity. The imaging, physi-
cal, and clinical findings seen in these patients
have received little attention in the radiologic
literature. Because many breast imagers are
unfamiliar with the disease process, which can
present with a wide variety of symptoms, di-
agnosis can be delayed and the time to initia-
tion of appropriate medical or surgical man-
agement prolonged.
Periductal mastitis and duct ectasia are con-
sidered part of the spectrum of the inflamma-
tory process. However, the underlying cause
of abscess and fistula formation is believed to
be lactiferous duct or periareolar follicle ob-
struction associated with squamous metapla-
sia and hyperplasia [1–8]. When the patho-
genesis of this disease process is understood, it
becomes easier to recognize the subtle yet typ-
ical imaging findings during diagnostic evalu-
ation of these patients.
Pathogenesis
Although several cases of nonpuerper-
al subareolar mastitis and abscess were de-
scribed in the late 1800s, the disease is cred-
ited to Zuska, who with his colleagues [2] in
1951 published the clinical and pathologic
findings of five patients with comedomastitis
complicated by recurrent abscess and fistula
of the lactiferous ducts. The five patients de-
scribed had recurrent drainage of the sinuses
of the areola, subareolar masses, and abnor-
mal nipple discharge. At pathologic review,
Zuska et al. found several major microscopic
findings, including acute and chronic inflam-
mation of the lactiferous duct, dilatation of
the duct, stasis, and desquamated keratinized
epithelium in the duct lumen. They attribut-
ed the disease process to stasis of secretions
within the duct that led to dilation and inflam-
mation or infection of the ampulla with ulcer-
ation and abscess formation. Rupture of the
abscess through the skin resulted in forma-
tion of a fistulous track.
In 1955, Atkins [3] hypothesized that block-
age of the duct (due to inverted nipples or some
other disease process related to lactation) and
not stasis was the main cause of this disease
process. Patey and Thackray [4] and Habif
et al. [5] theorized that squamous metaplasia
of the duct with proximal extension into the
subareolar duct led to the formation of kera-
tin plugs, which then obstructed the duct lu-
men, causing the extruded keratinized mate-

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 Kasales et al.

A B C
Fig. 1—Nonpuerperal subareolar abscess.
A, 38-year-old female smoker with right nipple discharge for several years and draining fistula that did not resolve with multiple courses of antibiotics and drainage.
Surgical excision of abscess was ultimately performed. Photomicrograph of histologic specimen shows findings typical of squamous metaplasia: normal one- or two-cell
layer of cuboidal epithelium (thin arrow) transitioning into region of hyperplastic squamous epithelium (thick arrow), producing large amounts of keratin, which form plugs
and obstruct major duct.
American Journal of Roentgenology 2014.202:W133-W139.

B, 33-year-old female smoker with recurrent abscess of left nipple-areolar complex. Photomicrograph of excised specimen shows cross section of dilated lactiferous
duct within left breast and hyperplastic and metaplastic squamous cells lining duct (thin arrow). Within dilated duct lumen and outside duct are islands of pink-stained
keratin debris (thick arrow). Multiple small blue-staining monocytes (arrowheads) are present within lumen and outside duct. They are produced as acute inflammatory
response to keratin debris and extruded acinar contents.
C, 33-year-old female smoker with chronic left subareolar abscess. Photomicrograph of excised specimen shows multinuclear giant cell (arrow), which formed because
of chronic inflammation and keratin debris.

rial to incite a foreign-body reaction in the
periductal tissue. They believed the process
was responsible for entities such as inflamed
comedo, infected sebaceous cysts, and epi-
thelial inclusion cysts of the nipple.
An alternative hypothesis of origin was put
forth by Kilgore and Fleming [6], Maier et al.
[7], and Berná-Serna and Berná-Mestre [8].
They theorized that subareolar abscess with fis-
tula could be caused by follicular obstruction of
the pilosebaceous unit of the periareolar tissue,
leading to hyperkeratinization and dilation of
the follicle. Rupture of the wall of the follicle
with leakage of keratin into the adjacent tissue
would then cause a secondary chemical inflam-
matory process, which superimposed with bac-
terial infection and abscess formation would re-
sult in fistula track formation extending to the
edge of the areola. The final appearance would
be identical to the appearance of abscesses and
fistulas caused by duct obstruction.
Histopathologic Findings
The breast is a modified sweat gland con-
taining 16–18 major lactiferous ducts that
drain multiple acini within a lobule. The ma-
jor ducts join and open at the apex of the nip-
ple and converge, dilating slightly to form an
ampulla that functions for secretory storage
[9]. In a normal lactiferous duct, squamous
epithelium is present within 1–2 mm of the
epidermal surface of the nipple. Deep to that
there is an abrupt change from squamous ep-
ithelium to a double layer of cuboidal or low
columnar epithelium.
In a nonpuerperal subareolar abscess, the
normal one- or two-cell layer of cuboidal ep-
ithelium of the distal duct transforms into
squamous epithelium. The squamous lining
produces large amounts of keratin, forming
keratin plugs that obstruct the major duct,
causing it to dilate as it accumulates secre-
tory material (Fig. 1A). With progressive di-
lation, the thin epithelial lining ruptures and
keratin is extruded, inciting an inflamma-
tory response to its contents (Figs. 1B). The
breast tissue reacts to the extruded keratin as
a foreign substance, prompting macrophages
to fuse and form foreign-body giant cells as
they try to remove the debris (Fig. 1C). Inva-
sion of bacteria can then lead to the develop-
ment of a subareolar abscess.
The subareolar abscess can drain spontane-
ously, forming a track that usually leads to the
vermillion border of the nipple. With time, the
track can form a chronic sinus or fistula. Recur-
rent abscess and persistent distal duct obstruc-
tion lead to continued accumulation of keratin
debris and chronic inflammation. The persis-
tence of monocytes and the infiltration of tissue
with lymphocytes denote a chronic inflamma-
tory process. As the breast tissue heals, cyto-
kines are secreted by macrophages and other
inflammatory cells, inducing fibrosis.
Formation of a subareolar abscess formed
as the result of follicular occlusion of the pi-
losebaceous unit of the areola is similar to the
formation of inflammatory skin lesions in hy-
dradenitis suppurativa. Chronic inflammation
of the pilosebaceous unit of a follicle along the
edge of the areola incites squamous metaplasia
of the follicle, causing it to become obstruct-
ed. The follicle dilates and its wall ruptures,
extruding keratin and leaking the contents of
the follicle into the adjacent subcutaneous tis-
sue, prompting an inflammatory response. Su-
perimposed infection can result in subareolar
abscess formation and fistula. Histologically,
the appearance is similar to that of an abscess
formed by major duct obstruction.
Clinical Presentation
Subareolar nonpuerperal mastitis and ab-
scess differs from lactational mastitis and
abscess in many respects. Peripuerperal ab-
scesses affect women of child-bearing age,
tend to be peripheral in location, and are as-
sociated with Staphylococcus aureus, S. al-
bus, and Streptococcus infections. Because
they are readily recognized and treated by
clinicians, puerperal abscesses represent the
minority (< 15%) of breast abscesses seen in
breast clinics [10, 11]. Recurrence is rare be-
cause lactational abscesses respond well to
antibiotic therapy and, when indicated, per-
cutaneous drainage.

W134 AJR:202, February 2014

 Mastitis and Subareolar Abscess

Fig. 2—44-year-old man with breast pain due to

subareolar abscess. Photograph from physical
examination shows palpable mass with erythema
(arrow). At surgical excision mass was found to
correspond to subareolar abscess. 

Fig. 3—35-year-old woman with subareolar abscess

and lactiferous fistula. Photograph shows erythema
and small ulceration formed by fistula track (arrow) at
edge of areola and vermillion border. 

Two types of nonpuerperal abscess have
been described and are differentiated by loca-
tion. Peripheral nonpuerperal abscesses occur
infrequently and are associated with trauma, fa-
cial acne, epidermal cysts, and chronic condi-
American Journal of Roentgenology 2014.202:W133-W139.
with the peak incidence in the mid to late fourth
decade [13, 14]. Although the disease process
has been reported in men, more than 95% of pa-
tients are women [13, 15–17]. A strong correla-
tion has been reported with cigarette smoking
Symptoms of nonpuerperal subareolar mas-
titis and abscess are closely related to the age
of the patient. Younger patients tend to have
more breast pain, possibly due to acute peri-
ductal inflammation. Breast pain can precede

tions such as diabetes and rheumatoid arthritis [18, 19], and an association with inadequate vi- the development of inflammatory masses. Pal-
[12]. Compared with lactational abscess, non- tamin supplementation (particularly vitamin A) pable masses related to inflammation and ab-
puerperal subareolar abscesses affect a wider has also been suggested [9]. Parity and lacta- scess are not rare and represent 3–4% of all
age range (mid teens through eighth decade) tion have not had a significant association [20]. benign breast masses [1]. When masses are

A C
Fig. 4—35-year-old female smoker with left breast subareolar abscess who underwent diagnostic mammography for evaluation of rapidly developing left breast lump
associated with erythema of nipple.
A, Mediolateral oblique mammogram shows skin thickening and nipple retraction (arrow).
B, Focused left breast ultrasound image shows skin thickening and subareolar collection (arrow). Calipers indicate solid component within collection
C, Power Doppler image shows hyperemia surrounding cavity. Patient underwent antibiotic treatment and was referred to breast surgery clinic. She initially responded
to antibiotics, but recurrent symptoms on left and new discharge, erythema, and mass on right developed when antibiotics were discontinued. Patient ultimately
underwent resection of both left and right subareolar regions. Pathologic finding was subareolar abscess on left and lactiferous fistula on right. Patient responded well
and required no additional therapy.

AJR:202, February 2014 W135

 Kasales et al.

Fig. 5—45-year-old woman with mass in left nipple caused by infected epidermal inclusion cyst. One year
earlier she had abscess in same area, which was treated with drainage, hot compresses, and antibiotics.
A, Left mediolateral oblique mammogram shows oval mass with obscured borders (arrow) in subareolar region.
B, Focused ultrasound image of left subareolar region shows oval circumscribed collection with thickened wall
in skin (arrow).
C, Photomicrograph of excised lesion shows unerupted epidermal inclusion cyst with associated acute and
chronic inflammation and rare histiocytes and foreign body giant cells.

A B C
American Journal of Roentgenology 2014.202:W133-W139.

present, they frequently are associated with er-
ythema (Fig. 2). Older patients often describe
less pain associated with palpable nipple mass-
es (possibly reflecting less acute inflammation
and greater amounts of fibrosis). At palpation
the masses can be poorly defined and fixed to
the adjacent tissue (owing to fibrosis), which
can also lead to nipple retraction, raising con-
cern about malignancy. Roughly 15–20% of
patients report discharge, variable in color and
consistency [1]. Younger patients tend to have
thinner discharge, whereas in older patients
the discharge may be more viscous.
Compared with lactational breast abscesses,
subareolar nonpuerperal abscesses recur more
frequently (> 50%) and often require multiple
drainage or surgical procedures [10]. Initial
cases of subareolar abscess are usually associ-
ated with Staphylococcus infections [12, 21],
but recurrent episodes often have mixed flo-
ra, including anaerobic organisms [10, 11, 15,
19, 22]. Fistulas form in as many as one third

Fig. 6—44-year-old male smoker with

palpable subareolar mass caused by
infected epidermal inclusion cyst.
A, Mediolateral oblique mammogram
of right breast shows asymmetric
thickening of skin of areola
(arrowhead).
B, Focused ultrasound image of
area in A shows collection (arrow,
calipers) within skin.
C, Photomicrograph of excised
specimen shows epidermal inclusion
cyst with acute and chronic
inflammation, foreign-body giant
cells, histiocytes, and fibrosis.
A C

W136 AJR:202, February 2014


of patients [10]. The tracks extend from the
abscess cavity or dilated duct to the skin sur-
face of the nipple, often forming a raised, en-
crusted lesion at the edge of the areola or ver-
million border (Fig. 3). Although fistulas can
form spontaneously, in two thirds of patients
they form after aspiration or an incision and
drainage procedure [1]. Higher rates of disease
recurrence and subsequent complicated recov-
ery have been linked to the presence of mixed
flora, anaerobic bacteria, Proteus organisms,
and cigarette smoking. Age, sex, race, alcohol
or illicit drug use, and comorbid conditions
have not been not associated with disease re-
currence [11, 19].
Imaging Findings
Little has been published regarding the im-
aging findings of Zuska disease. Mammograph-
ic findings most frequently described include
a mass (usually ill defined), focal or diffuse
American Journal of Roentgenology 2014.202:W133-W139.
asymmetry, and normal mammographic find-
ings [23–25]. Lesions range in size from 1.0
to 5.0 cm (median, 2.0 cm) [23]. Ultrasound
findings include complex cystic lesions (≈ 50%
of cases) and nonspecific heterogeneously hy-
poechoic masses [23–25].
We performed an institutional review board–
exempt retrospective review of the mammo-
graphic and ultrasound imaging findings in 26
patients with nonpuerperal subareolar mastitis
treated by a single experienced breast surgeon
at our institution. A single pathologist with ex-
pertise in breast imaging reevaluated the his-
topathologic slides of patients who had under-
gone imaging studies to verify the diagnosis
and aid in imaging-pathologic correlation. Im-
ages from a total of 16 mammographic and 21
ultrasound examinations were available for 23
patients. At mammography the most common
findings were anterior skin thickening (7/16,
44%) and a normal mammogram (3/16, 19%).
Only 3 of 16 patients had mammographically
visible masses (one round and circumscribed,
one oval with indistinct borders, and one ir-
regular). One patient had focal asymmetry at
mammography. At ultrasound 16 of 21 pa-
tients (76%) had evident subareolar or areolar
skin collections, and 13 of the 16 collections
(81%) were associated with skin thickening.
Isolated skin thickening was noted in 2 of 21
patients (10%) (Figs. 4–9). In many instances,
even when the mammographic findings were
normal, ultrasound revealed small collections.
Technique is extremely important in perfor-
mance of the ultrasound examination. Most of
the affected area is around the nipple, an area
that can be challenging to examine with ultra-
AJR:202, February 2014 W137
Mastitis and Subareolar Abscess
A B
Fig. 7—30-year-old woman with right breast abscess who presented to breast center with palpable mass
in subareolar region of right breast, inverted nipple, report of milky nipple discharge, and history of similar
symptoms in left breast 2 years earlier, which resolved after surgical excision of epidermal inclusion cyst.
A, Ultrasound image shows heterogeneous hypoechoic irregular mass with circumscribed margins (arrow).
B, Color Doppler image shows increased flow in periphery of lesion. Area was surgically aspirated for culture,
which grew staphylococci and enterococci. Course of antibiotic therapy was prescribed. Three weeks later
patient underwent resection of right breast abscess. She did well and had no further symptoms.
sound. Generous use of warm coupling gel is
warranted to assure adequate contact between
the probe and the skin surface and to reduce
contraction of the musculature of the areola,
which can cause artifacts related to wrinkling
of the skin [26]. Standoff pads may also prove
helpful, although the pressure of the pad with
scanning may obscure abnormalities by effac-
ing superficial findings. Various techniques to
improve visualization of the subareolar ducts
and nipple have been described. They are de-
signed to help place the nipple and subareo-
lar ducts perpendicular to the insonating ultra-
sound beam. Each technique requires imaging
in the radial plane while the nipple is rolled or
folded to allow full contact of the transducer
Fig. 8—26-year-old female smoker who found
along the long axis of the ducts as they extend subareolar right breast mass during self-examination.
into the nipple [26, 27]. Focused ultrasound image shows small cystic mass
(arrow) with central solid material located within
base of nipple. Patient was referred to breast surgery
Differentiating Subareolar Mastitis clinic for excisional biopsy. At surgery small abscess
From Malignancy cavity was excised. Patient had no further symptoms.
In the evaluation of patients with clinical
findings of subareolar mastitis (skin thicken- per outer quadrant [28]. Subareolar mastitis
ing and subareolar mass), the main concern more commonly presents with skin thicken-
is whether the patient has malignancy, partic- ing and edema and a retroareolar mass [1].
ularly inflammatory carcinoma of the breast. The mammographic findings of inflamma-
Clinically there are slight differences in the tory breast cancer (skin thickening, trabecu-
patient populations. First, the mean age of lar prominence or edema, asymmetric density)
women with inflammatory breast cancer is are similar to those of subareolar mastitis [28].
roughly one decade older than that of women Normal mammographic findings are not rare
with subareolar mastitis [28]. At physical ex- in either entity. At ultrasound both subareo-
amination, inflammatory breast cancer most lar mastitis and inflammatory breast cancer
commonly presents with skin changes (peau exhibit skin thickening with high frequency.
d’orange or erythema) and a palpable mass, Subareolar masses (mixed cystic and solid) or
the latter more frequently found in the up- collections are often evident at ultrasound in

subareolar mastitis [23], whereas 80% of car-
cinomas associated with inflammatory breast
cancer appear solid [29]. Compared with mas-
titis, inflammatory cancer is more likely to ex-
hibit a mass at ultrasound [28].
Several studies have evaluated the utility
of other imaging modalities in differentiat-
ing inflammatory carcinoma from mastitis.
Technetium 99m–sestamibi scintimammog-
raphy has not been found useful because
both carcinoma and acute inflammation (in
the absence of malignancy) frequently cause
positive results [30]. Breast MRI, however,
shows promise.
In patients with inflammatory breast cancer,
contrast-enhanced MRI has had high accura-
cy in defining the primary lesion [31]. Several
studies have also shown that the MRI charac-
teristics differ between patients with mastitis
and those with inflammatory breast cancer.
The morphologic features of lesions (masses
American Journal of Roentgenology 2014.202:W133-W139.
and nonmasslike enhancement), skin thicken-
ing, edema, and nipple configuration are simi-
lar in both groups [28]. However enhancement
characteristics have been reported to differ be-
tween the two groups [28, 32]. Renz et al. [28]
reported that 85% of the tumors found in in-
flammatory breast cancer exhibited initial ear-
ly enhancement greater than 100%, whereas
only 45.2% of the MRI-visible lesions in pa-
tients with mastitis were greater than 100%
enhancing (p < 0.0001). Curves after initial
enhancement also differed, showing washout
more frequently in carcinoma (68.8%), where-
as mastitis exhibited plateau or persistence in
42.9% of cases [28]. In addition, the location
of lesions (both nonmasslike enhancement
and masses) evident at MRI also differed. Le-
sions were located either centrally within the
breast or were dorsal in patients with inflam-
matory breast cancer, whereas lesions of mas-
titis were more frequently subareolar [28]. De-
spite these differences, histologic diagnosis
(through aspiration and culture or core needle
biopsy) remains integral to the treatment of
these patients [32].
Treatment
Treatment of nonpuerperal mastitis and sub-
areolar abscess of the breast is debated in the
literature. Although puerperal abscesses are
readily managed with antibiotics and ultra-
sound-guided aspiration and drainage, such
regimens often fail in the management of
nonpuerperal abscesses. Many authors advo-
cate early surgical intervention with excision
of the abscess, sinus track, and the involved
terminal portion of the subareolar duct be-
cause of the high recurrence rate with medi-
W138 AJR:202, February 2014
Kasales et al.
cal treatment [15, 33]. Others emphasize that
medical management, including appropri-
ate antibiotic coverage and abscess drainage,
should initially be attempted and that surgical
intervention be reserved for cases in which
medical management fails and cases of dis-
charge from multiple ducts [13, 14].
Ultrasound-guided aspiration and drain-
age with antibiotic therapy has been found
effective in the treatment of both puerper-
al and nonpuerperal abscesses [21, 33–37].
Success rates of 98% for puerperal breast ab-
scesses and 81% for nonpuerperal breast ab-
scesses treated with one ultrasound-guided
drainage procedure have been reported, bet-
ter success being associated with the pres-
ence of a puerperal abscess [33].
Berná-Serna et al. [34, 38] reported sim-
ilar success rates in two separate studies of
the treatment of multiple patients with breast
abscesses. Simple aspiration for collections
smaller than 3 cm and percutaneous catheter
drainage or incision and drainage of collec-
tions larger than 3 cm were successful in man-
aging both lactational and nonlactational ab-
scesses. However, the authors emphasized that
in chronic abscesses the treatment of choice
remained surgical excision and that percutane-
ous drainage was an intermediate therapeutic
option. They also emphasized that in nonpu-
erperal abscesses, multiple aspiration or drain-
age procedures were often required (Fig. 9).
A growing body of literature supports re-
section of the obstructed subareolar duct or
ducts and associated abscess and fistula from
the initial presentation in patients with non-
puerperal subareolar abscess. Lower recur-
rence rates have been reported among pa-
tients whose treatment included excision of
the lactiferous ducts (28%) than among those
whose treatment did not (79%) [15].
Three main surgical techniques have been
emphasized in the surgical literature. Meguid
et al. [9] described the use of a transverse inci-
sion from the middle of the nipple (to include
the diseased duct) laterally through the areola
to the vermilion border. In the Hadfield proce-
dure, a circumferential skin incision is made
along the inferior margin of the areola and in-
cludes the opening of any sinus or fistula that
may be present, allowing the nipple to be re-
flected away from the breast [39, 40]. The ra-
dial technique promoted by Urban [41] entails
a radially oriented incision to produce an el-
lipse of skin that extends from the base of the
nipple to the abnormal region. The ovoid de-
fect produced with this technique is then oblit-
erated by approximating the remaining soft
tissue to form a supportive structure for the
Fig. 9—36-year-old female nonsmoker with recurrent
bilateral folliculitis, mastitis, abscess, and history
of hydradenitis suppurativa who presented to clinic
reporting chronic bilateral nipple discharge, left
greater than right. Initial workup included bilateral
mediolateral oblique and craniocaudal mammograms
and ultrasound of subareolar region of left breast.
Findings were normal, but symptoms progressed.
Five months later patient presented with palpable
left subareolar mass with local erythema. Focused
left breast ultrasound image shows large collection
(arrows) that was drained surgically and grew Proteus
organisms. Patient had persistent drainage from
left breast over next 7 months, and nipple retraction
ultimately developed. Subareolar excision was
performed. Pathologic finding on excised area was
acute and chronic inflammation and folliculitis. Left
breast symptoms resolved. Seven months later patient
presented with rust-colored discharge from right
breast and underwent surgical exploration. Pathologic
assessment revealed epidermal inclusion cyst with
acute and chronic inflammation and focal mastitis.
Over next 7 months she underwent multiple right
breast excisions in attempt to control chronic pain
and drainage. After development of multiple recurrent
abscesses and fistulas, patient ultimately underwent
partial mastectomy and remained symptom free.
areola and nipple as the margins of the skin
defect are closed, producing a good cosmet-
ic result [14]. The major goal of all three sur-
gical procedures is isolation and resection of
the affected ducts and fistulas. Each approach
requires either wound packing or temporary
drain placement in the immediately postoper-
ative period. Before surgery, evaluation with
contrast-enhanced MRI with high-resolution
microscopy coils can provide detailed infor-
mation about abscess and fistula location and
the overall extent of disease, improving surgi-
cal planning for these patients [25].
The long-term outcomes among patients
with subareolar abscess have not been fully
examined. In one study, breast cancer screen-
ing of 277 patients with nonpuerperal mastitis
within a year of the mastitis diagnosis showed
that five women had noninflammatory breast
cancer, all but one located at a site different
from the location of mastitis. The women were

not at high risk according to history. Com-
pared with the local incidence of breast can-
cer among women, this represented a 37-fold
increase in risk, suggesting these women may
be at increased risk of a cancer diagnosis with-
in 12 months after treatment of mastitis [42].
Conclusion
Nonpuerperal subareolar mastitis and ab-
scess is a rare but debilitating process caus-
ing considerable morbidity. With prompt
recognition of the clinical and often subtle
imaging findings, the appropriate diagnosis
can be made, expediting treatment. Various
therapeutic options, including antibiotic cov-
erage, ultrasound-guided drainage, and sur-
gical excision, can then be more rapidly ini-
tiated, improving patient care and reducing
the prolonged morbidity usually associated
with the disease process.
American Journal of Roentgenology 2014.202:W133-W139.
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