Galactocele while breastfeeding: A case study of an infected galactocele and its resolution with fine needle aspiration

This article is my own journey of galactocele resolution while breastfeeding. It was written for publication in a journal  but wasn’t published. At the time this occurred I was unable to find any information (either first or second-hand) about galactoceles and their resolution while breastfeeding and felt incredibly alone in the journey. If you have personal questions please don’t hesitate to reach out.

Abstract

Galactocele is a rare form of benign, cystic lesion in the breast, and is typically observed in pregnant, lactating or post‑lactational women. Galactoceles typically present as a painless, palpable mass, and are typically <3 cm in size. In this case study, a large (>100 mL volume), infected, painful galactocele was observed and resolved through repeated fine‑needle aspiration. During the last aspiration, the galactocele was ‘flushed’ with saline solution. Breastfeeding was maintained throughout the treatment and continued post aspiration. In conclusion, repeated fine‑needle aspiration, with a final ‘rinse’ with saline, can negate the need for surgical removal of a galactocele, enabling breastfeeding to be maintained with minimal breast trauma. Women with unidentified lumps in their breasts should seek medical advice from an experienced breast surgeon and lactation consultant, which can improve the information obtained, minimise breast trauma and enable continued breastfeeding.

Introduction

A galactocele is a rare form of cystic lesion of the breast (Golden & Wangensteen, 1972; Langer et al., 2015; Yu et al., 2013) and is the most common benign breast lesion in lactating women (Couto, Glassman, Abreu, & Paes, 2016; Hosny, Eldin, & Elghawabi, 2011). Galactoceles are typically detected during pregnancy, breastfeeding or post‑lactation, presenting as a painless, palpable mass (Langer, et al., 2015; Yu, et al., 2013). However, they have also been recorded in male infants (Rahman, Davenport, & Buchanan, 2004; Vlahovic et al., 2012), prepubertal girls (Alaniz, Jeudy, Pearlman, & Quint, 2017) and in women post breast augmentation surgery (Bouhassira, Haddad, des Roziers, Achouche, & Cartier, 2015; Chun & Taghinia, 2009; Tung & Carr, 2011), with a higher incidence in those experiencing pituitary prolactinoma (Poiana, Chirita, Carsote, Hortopan, & Goldstein, 2009; Tseng, Liao, Hsu, & Chen, 2016). They form due to the obstruction of a lactiferous duct and the subsequent accumulation of milk or milky fluid (Poiana, et al., 2009).

While alternative treatments such as nylon probing have been suggested (Auvichayapat et al., 2003), successful galactocele diagnosis and treatment usually involves a combination of ultrasound and fine needle aspiration (Yu, et al., 2013), which is particularly therapeutic in cases of large, more than 3 cm galactoceles (Hosny, et al., 2011; Sawhney et al., 2002). If a galactocele is not treated, and contents leak within the breast, chronic inflammation and fat necrosis can be observed (Yu, et al., 2013) and galactocele infection has been reported (Ghosh, Morton, & Whaley, 2003).

This case study describes the resolution of a large (>4 cm diameter), infected galactocele that was treated with repeated fine needle aspiration under ultrasound guidance.

History and observational assessment

A caucasian woman, 28 years of age with two children, presented with a large, hard mass in her right breast in the 12 O’clock position. She had breastfed her first child for three years with no complications prior to falling pregnant with her second baby. The woman had experienced mastitis three times during this second postpartum period: twice in the right breast in the 12 O’clock position, and once in the left breast. These occurrences of mastitis were treated with frequent massage and warm compresses during feeding, expressing, cold compresses and cabbage leaves between feeds, ibuprofen and 3‑4 L of water consumption per day. Additionally, the woman took daily supplements including 1 g of vitamin C (Blackmores Bio C Chewable), 1200 mg sunflower lecithin (Thompsons), two sachets of probiotics (Qiara), 1 g garlic extract (Nutralife Kyolic), 1 capsule of B vitamin complex (Research Nutrition BioActive B‑Complex), 1 capsule of trace minerals (Research Nutrition TraceMins Complex), 1 g of concentrated Omega‑3 triglycerides (Orthoplex BioActive Lipids) and immunity boosting herbs (Garlic, Echinacea, Elderberry, Horse‑Radish). While this treatment repeatedly resolved the mastitis, the woman’s right breast was traumatised and bruised, and she reported her nipples had been grazed, blistered, cracked and bleeding. The baby was assessed and revised for a tongue‑tie at two weeks old which improved latch, reduced nipple pain and eliminated nipple trauma and the frequent blocked ducts and mastitis.

Overall, the woman presented with multiple issues with the mother‑baby breastfeeding dyad, including recurrent mastitis, a persistent lump in her right breast, vasospasm, forceful let‑down, an oversupply and nipple trauma in the mother, and a tongue‑tie, high palate and shallow latch in the baby. These factors combined to create a difficult case to assess and rectify, and required management from many angles from the mother’s positioning and attachment to the baby’s latch and sucking reflexes.

Timeline

Table 1. A chronological summary of the events leading to the presentation and resolution of the galactocele.

Management

The woman noticed a large (>3 cm) lump in her breast three weeks prior to seeking treatment, and after initially treating for mastitis, discontinued treatment (Table 1). One week later, the woman experienced pain in her right breast where the lump was located and reported the lump to be ¼ the size of her breast, so again treated for mastitis. Treatment was received from an acupuncturist and Traditional Chinese Medicine (TCM) herbs were taken in combination to the home treatments aforementioned. Due to lack of improvement, further treatment from a physiotherapist who used therapeutic ultrasound, electrode stimulation, remedial massage and acupuncture was received to resolve the blockages and lump in the right breast (Table 1). The woman reported a reduction in the size of the lump after having breastfed or expressing breastmilk (Figure 1), and spoke with a lactation consultant who suggested ‘dangle feeding’ (Figure 2), pumping three hourly and continuing other treatments, but also seeking a diagnostic ultrasound to rule out a galactocele.

Three days later, when the breast had been fully drained, diagnostic ultrasound revealed a 46 * 32 * 45 mm galactocele. Upon medical advice, the woman ceased treatment but ensured the breast was emptied each feed. Over the next two days, the lump increased in size substantially, taking up most of the breast and distorting nipple shape. This eventually resulted in another case of mastitis along with galactocele infection. An on call GP prescribed Flucloxacillin but recommended no further treatment. The following day, the woman woke with a swollen right armpit which caused pain when lifting the arm. Through familial contacts, the woman spoke with a breast surgeon who recommended prompt treatment.

The woman visited an International Board Certified Lactation Consultant (IBCLC) at a drop in clinic two days later, and received advice on different latching positions and ways to feed the baby to help to drain the breast and accordingly the galactocele. At this appointment, vasospasm, an oversupply, a forceful let down, an infected galactocele and mastitis was observed in the woman, and the baby was recorded as having a high palate, potentially remaining tongue tie and accordingly, a shallow latch (Figure 3). The lactation consultant provided suggestions on exercises to assist baby to improve latch and organised a follow up appointment for after the appointment with the breast surgeon.

The following day, the breast surgeon aspirated 100 mL of green, watery milk, followed by pussy milk and then blood from the galactocele. The aspirate was sent to pathology and cystology, revealing that the lump was a galactocele infected with Staphylococcus aureus. Solidifed milk remained in the breast, and so a small lump was still present after treatment, though the pain and movement limitations were relieved, the baby was able to latch and feed correctly and the redness and pain dissipated. After this treatment, the woman received further suggestions on positioning and attachment at the breast from the IBCLC, and the woman continued the antibiotic treatment and feeding, but stopped expressing, massage, warm and cold compresses and TCM herbs. The galactocele refilled to about half the size within an hour of leaving the breast surgeon and remained that size for the following two days with a return of pain in the woman’s right armpit, and pain and redness in her right breast.

Two days later, the breast surgeon aspirated 45 mL of bloody puss from the galactocele, and again within two hours of this aspiration the galactocele had returned to half its previous size, but with much less pain and redness. Four days later, the woman returned to the breast surgeon who aspirated a further 20 mL of bloody puss from the galactocele. Two days later, after no return of pain or tenderness but slight refilling of the galactocele, the woman returned to the breast surgeon who aspirated 5 mL of blood, no puss, indicating that the infection had cleared. As there were still some hard, lumpy bits around the galactocele (blood clots) the breast surgeon ‘flushed’ the galactocele with saline until the saline ran clear.

The management and resolution of this galactocele involved four FNA’s and final ‘flushing’ of the galactocele, three repeat scripts of Flucloxacillin and consumption of 3‑4 L each day. Additionally, the woman took supplements daily of 1 g of vitamin C (Blackmores Bio C Chewable), 1200 mg sunflower lecithin (Thompsons), two sachets of probiotics (Qiara), 1 g garlic extract (Nutralife Kyolic), 1 capsule of B vitamin complex (Research Nutrition BioActive B‑Complex), 1 capsule of trace minerals (Research Nutrition TraceMins Complex), 1 g of concentrated Omega‑3 triglycerides (Orthoplex BioActive Lipids) and immunity boosting herbs (Garlic, Echinacea, Elderberry, Horse‑Radish).

Outcomes

This final treatment (FNA and ‘flushing’) resolved the galactocele and the woman reported no pain or tenderness, no recurrence of mastitis, ease of feeding and ability to continue breastfeeding for many months. However, an unanticipated event occurred 31 weeks later, when the woman experienced another bout of mastitis in the same location as the prior galactocele, and while she managed this in the same way as described previously (breast ultrasound, massage, water, ibuprofen and supplementation), a lump remained at the end of treatment. One week later, breast ultrasound confirmed a 14 * 10 * 13 mm region of tissue at the 12 O’clock position on the right breast. One week later, the woman revisited the breast surgeon and had FNA under ultrasound guidance, during which approximately 1 mL of fluid was retrieved and sent for pathology and cytology, which was inconclusive. A small, hard lump approximately 5 mm in diameter remains in the woman’s right breast, but causes no difficulties with breastfeeding, no pain, is not infected and has not resulted in recurrent mastitis.

Discussion

Repeated fine needle aspiration under ultrasound guidance resolved the large (>4 cm), infected galactocele, as is consistent with previous reports (Hosny, et al., 2011; Sawhney, et al., 2002; Yu, et al., 2013). Earlier diagnosis and treatment of the galactocele described in this case study would likely have yielded better results, potentially avoided the recurrence of the galactocele and would have minimised the pain, inflammation and infection experienced by the woman, as has been reported in previous studies (Ghosh, et al., 2003; Langer, et al., 2015; Yu, et al., 2013). It is possible that the woman in this case study has pituitary prolactinoma, given the association between galactocele formation and prolactinoma (Poiana, et al., 2009; Tayae & Jamor, 2017; Tseng, et al., 2016), but further research is required to extrapolate such a diagnosis. Although alternative treatment methods have been proposed (Auvichayapat, et al., 2003), the only treatment available at the time of this case was fine needle aspiration. While fine needle aspiration did resolve the galactocele in this instance, the breast tissue scarring potentially enabled the recurrence of the galactocele, and also recurrent blocked ducts (Table 1). Accordingly, future patients, surgeons, doctors and lactation consultants may benefit from research into less invasive methods of galactocele resolution, particularly when breastfeeding is to be maintained.

It is imperative that women with a galactocele are provided referrals to a supportive IBCLC and potentially an experienced breast surgeon, alongside receiving support from a knowledgeable and informed GP. The woman in this case study reported that the majority of health care providers she spoke with hadn’t heard of a galactocele, much less knew how to treat it, and often provided medical advice outside their scope of practice which did not assist resolution of the galactocele. The woman further noted that it was only through receiving treatment from experienced, supportive health professionals that she was able to continue to breastfeed and avoid surgical removal of the galactocele.

Finally, every palpable lump, no matter how small or reoccurring, should be assessed by an experienced breast surgeon with ultrasound, potentially FNA and/or core biopsy as required. This management procedure would reduce the trauma sustained by the patient, would reduce the risk of undiagnosed malignant tumours and would support the mother‑baby breastfeeding relationship to continue post galactocele resolution.

Conflicts of interest statement

The author declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This article was written with the support of Decalie Brown (IBCLC) in 2017 but has not been further assessed for publication on this blog. 

References

Alaniz, V. I., Jeudy, M., Pearlman, M., & Quint, E. H. (2017). Galactocele in a prepubertal girl. Journal of Pediatric and Adolescent Gynecology, 30(4), 499-500.
Auvichayapat, P., Auvichayapat, N., Tong-un, T., Thinkhamrop, B., Vachirodom, D., & Uttravichien, T. (2003). A controlled trial of a new treatment for galactocele. Journal of the Medical Association of Thailand, 86(3), 257-261.
Bouhassira, J., Haddad, K., des Roziers, B. B., Achouche, J., & Cartier, S. (2015). Lactation after breast plastic surgery: Literature review. Annales De Chirurgie Plastique Esthetique, 60(1), 54-60.
Chun, Y. S., & Taghinia, A. (2009). Hyperprolactinemia and galactocele formation after augmentation mammoplasty. Annals of Plastic Surgery, 62(2), 122-123.
Couto, L. S., Glassman, L. M., Abreu, D. C. B., & Paes, J. F. (2016). Chronic galactocele. Breast Journal, 22(4), 471-472.
Ghosh, K., Morton, M. J., & Whaley, D. H. (2003). Infected recurrent galactocele – A management dilemma. Journal of General Internal Medicine, 18, 53-53.
Golden, G. T., & Wangensteen, S. L. (1972). Galactocele of breast. American Journal of Surgery, 123(3), 271-+.
Hosny, I. A., Eldin, L. A. S., & Elghawabi, H. S. (2011). Radiological evaluation of palpable breast masses during pregnancy and lactation. The Egyptian Journal of Radiology and Nuclear Medicine, 42(2), 267-273.
Langer, A., Mohallem, M., Berment, H., Ferreira, F., Gog, A., Khalifa, D., . . . Cherel, P. (2015). Breast lumps in pregnant women. Diagnostic and Interventional Imaging, 96(10), 1077-1087.
Poiana, C., Chirita, C., Carsote, M., Hortopan, D., & Goldstein, A. (2009). Galactocele and prolactinoma – A pathogenic association? Maturitas, 62(1), 98-102.
Rahman, N., Davenport, M., & Buchanan, C. (2004). Galactocele in a male infant with congenital hypopituitarism. Journal of Pediatric Endocrinology & Metabolism, 17(10), 1451-1453.
Sawhney, S., Petkovska, L., Ramadan, S., Al-Muhtaseb, S., Jain, R., & Sheikh, M. (2002). Sonographic appearances of galactoceles. Journal of Clinical Ultrasound, 30(1), 18-22.
Tayae, M., & Jamor, J. (2017). A rare case of giant galactocele associated with prolactinoma. Pan African Medical Journal, 27.
Tseng, Y. S., Liao, Y. Y., Hsu, C. C., & Chen, K. T. (2016). Nonpuerperal mastitis acts as the initial presentation of pituitary prolactinoma. Breast Journal, 22(6), 697-698.
Tung, A., & Carr, N. (2011). Postaugmentation galactocele a case report and review of literature. Annals of Plastic Surgery, 67(6), 668-670.
Vlahovic, A., Djuricic, S., Todorovic, S., Djukic, M., Milanovic, D., & Vujanic, G. M. (2012). Galactocele in male infants: Report of two cases and review of the literature. European Journal of Pediatric Surgery, 22(3), 246-250.
Yu, J. H., Kim, M. J., Cho, H., Liu, H. J., Han, S.-J., & Ahn, T.-G. (2013). Breast diseases during pregnancy and lactation. Obstetrics & Gynecology Science, 56(3), 143-159.