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Treatment of Breast Abscesses with US-guided Percutaneous Needle Drainage without Indwelling Catheter Placement¹

¹ From the Department of Radiology, Methodist Hospital, Indianapolis, Ind (G.W.H.), and the Department of Radiology, Stanford University School of Medicine, Rm S-068A, Stanford, CA 94305-5105 (D.M.I.). Received May 7, 1998; revision requested July 10; final revision received February 17, 1999; accepted March 26. Address reprint requests to D.M.I. (e-mail: dikeda@stanford.edu).

	Abstract

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PURPOSE: To assess ultrasonographically (US) guided needle aspiration of breast abscesses as an alternative to surgical incision and drainage or indwelling catheter placement.

MATERIALS AND METHODS: The authors reviewed hospital records from 1995 to 1997 for patients undergoing US-guided aspiration of breast abscesses. Two radiologists reviewed the US, mammographic, and US-guided aspiration studies for the size, appearance, and drainage of abscesses. The medical records were reviewed for follow-up data.

RESULTS: Thirteen patients aged 15–69 years underwent US-guided percutaneous aspiration of 13 breast abscesses. All patients presented with a palpable mass, nine of which were retroareolar. At US, four abscesses were oval, nine (including three with septa) were irregularly shaped, and five had a thick rind. Of seven abscesses 2.4 cm or smaller, two were almost completely drained and five were completely aspirated. All seven abscesses resolved without surgery. Of six women with incompletely aspirated abscesses larger than 2.4 cm (one 3 cm, four 4 cm, one 7 cm), five required surgical referral; one of these cases was referred after repeat aspiration had been performed.

CONCLUSION: Percutaneous aspiration of breast abscesses can enable diagnosis of abscesses and be used to treat small abscesses if they are completely drained. Partial drainage of abscesses larger than 3 cm may be palliative, but incision and drainage still may be necessary for definitive treatment.

Index terms: Abscess, percutaneous drainage, 00.1262 • Breast, abscess, 00.212 • Breast, US, 00.129850, 00.12986 • Ultrasound (US), guidance, 00.12985, 00.12986

	Introduction

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Treatment of breast abscesses is a difficult clinical problem. The surgical literature describes classic abscess treatment as that consisting of an incision over the point of maximal tenderness and digital disruption of abscess septa with the patient under general anesthesia. The abscess cavity is left open and packed with gauze, and there are subsequent dressing changes for up to 6 weeks during wound granulation (1,2). Cosmetic results are often disappointing owing to scar formation. After the administration of antibiotics, abscess incision and drainage are still required because the abscess capsule prevents adequate contact between the antibiotic and the organisms. Even with this aggressive approach, the abscess recurrence rate is reported to be between 10% and 38% (3).

Ultrasonography (US) has been shown to be useful in depicting abscesses in patients with mastitis (4,5) and subsequently has been used to guide abscess drainage. A group of Scandinavian investigators (6) reported on their treatment of breast abscesses in four patients with techniques developed for percutaneous abdominal abscess treatment. Use of polyethylene pigtail catheters to drain and irrigate the abscesses resulted in improved cosmetic results and no abscess recurrences. Three years later, the same group reported on 19 additional patients who were treated with this regimen and had similar results (7). In a British study (2), blind needle aspiration of breast abscesses without placement of an indwelling catheter was evaluated, and it was found that several separate attempts at aspiration usually were required for complete abscess resolution; these findings raised the question of which approach is best for breast abscess treatment. In another British study (8), 19 of 22 patients with abscesses were treated successfully with needle aspiration only, but neither the abscess sizes nor the aspiration and guidance methods were elucidated.

It is conceivable that US guidance may facilitate complete drainage of breast abscesses compared with blind aspiration because US enables visualization of multiple abscess loculations. It is possible that loculated abscesses were the reasons for the repeat aspirations in the British studies. We performed this retrospective study to determine whether US-guided needle aspiration without the use of an indwelling catheter is a feasible alternative treatment option for breast abscesses.

	MATERIALS AND METHODS

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We reviewed medical records from Methodist Hospital for the period April 1995 to December 1997 for data on patients who underwent percutaneous breast abscess drainage with US guidance. Two radiologists (G.W.H., D.M.I.) reviewed the US and mammographic studies from the study population. The mammograms and US images were reviewed at the same time by both radiologists together to reach a consensus. All US examinations were performed with an Acoustic (Phoenix, Ariz) imaging unit and a 7.5-MHz transducer. The US aspiration studies were reviewed for abscess size, location, and appearance; the presence of loculations; and the amount of fluid remaining after aspiration. The mammograms were obtained by using dedicated mammographic units (GE 600T; GE Medical Systems, Milwaukee, Wis) and reviewed for breast density, presence or absence of mass, mass size and location, and correlation to palpable findings.

The needles used for abscess drainage, which ranged in size from 25 to 18 gauge, were placed into all abscess cavities by using direct US guidance, and the amount of pus aspirated was recorded. In one patient, a 5-F catheter was used for drainage because of an anticipated 200-mL volume of pus. In this case, the abscess cavity was irrigated with 50 mL of sterile saline solution and redrained, and the catheter was removed at the end of the procedure.

All aspirate samples were sent for pathologic examination and for aerobic and anaerobic culture analysis. Postprocedural US images were obtained to evaluate any residual fluid collections. The patients' medical charts were reviewed by one radiologist (G.W.H.) for presentation, treatment, and follow-up data. When follow-up information was unavailable on the medical chart, which was the case in seven patients, the patient's referring physician was contacted for this information.

	RESULTS

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Fifteen patients underwent US-guided, percutaneous drainage for suspected breast abscess during the study period. Two patients were excluded from the study because their pathologic examination results demonstrated concurrent neoplasms. Thus, the study group consisted of 13 patients (age range, 15–69 years; median age, 40 years). One patient had bilateral subareolar breast abscesses, but only one of the two abscesses was aspirated and thus included in the study. Thus, a total of 13 abscesses were reviewed.

Three patients were lactating (Fig 1), two of whom were less than 10 weeks postpartum (Table). The third patient was 2 years postpartum but still breast feeding. The abscess in the one adolescent patient may have been related to breast-mouth contact during sexual activity. The remaining nine patients were adults, and the causes of their abscesses were unknown.

View larger version (187K): [in this window] [in a new window]   Figure 1. Transverse US image of a 4-cm, irregularly shaped abscess (arrows) with septa in the breast of a 31-year-old postpartum woman. Aspiration yielded small amounts of thick pus. The abscess was treated with incision and drainage.

Mammography was performed in 10 patients. Seven mammograms depicted the abscess as an ill-defined mass, two depicted it as a focal density obscured by surrounding dense glandular tissue, and on one mammogram, the mass was not seen because of dense tissue. In the nine cases in which a mammographic finding was present, the mass or density corresponded to the palpable abscess.

US demonstrated a hypoechoic breast mass in all patients. The US appearances of the abscesses in the patients are noted in the Table. The abscesses were fairly well defined cavities with low-level echoes and through transmission of sound. The abscesses were oval in four and irregularly shaped in nine patients (four with septa, five with thick abscess rinds). All abscesses contained debris. The abscesses ranged in size from 0.8 to 7.0 cm (average size, 2.8 cm).

The aspiration procedures yielded volumes of pus that ranged from less than 1 mL to 200 mL (with irrigation) (Table). Postprocedural US demonstrated no residual fluid collection in five patients; the other patients had varying amounts of residual pus.

There was a difference in abscess resolution after aspiration between patients who had abscesses smaller than 3 cm and those with larger abscesses. Of seven patients with abscesses 2.4 cm or smaller (Fig 2), one had a thick rind, one had marked debris, and one had thick septa (Table). At aspiration, five of these seven abscesses were completely drained of pus, and the remaining two had only small amounts of fluid left. None of the seven 2.4-cm or smaller abscesses recurred after the needle drainage and antibiotic therapy, and none required repeat aspiration.

View larger version (167K): [in this window] [in a new window]   Figure 2a. Breast abscess drainage with US guidance in a 55-year-old woman. (a) Transverse US image shows the needle (arrows) inside a 1.3-cm, irregularly shaped breast abscess cavity (arrowheads). The small rectangle is the annotation marker on the screen. (b) On the transverse US scan obtained after drainage, there are tiny loculations (arrows) remaining in the cavity, which was almost completely drained. The abscess resolved with antibiotic therapy.

View larger version (170K): [in this window] [in a new window]   Figure 2b. Breast abscess drainage with US guidance in a 55-year-old woman. (a) Transverse US image shows the needle (arrows) inside a 1.3-cm, irregularly shaped breast abscess cavity (arrowheads). The small rectangle is the annotation marker on the screen. (b) On the transverse US scan obtained after drainage, there are tiny loculations (arrows) remaining in the cavity, which was almost completely drained. The abscess resolved with antibiotic therapy.

One patient had a history of inverted nipples and recurrent 4-cm bilateral subareolar abscesses. One of the two abscesses was aspirated and yielded 16 mL of pus. Subsequent aspiration and antibiotic therapy failed to resolve either of the two abscesses, and the patient underwent bilateral subareolar abscess resection, with nipple reconstruction 1 month later. In three patients with abscesses larger than 2.4 cm, aspiration yielded a small amount of pus compared with the size of the abscess, and these women were referred for incision and drainage (Table). The needle sizes in these cases were 20, 21, and 22 gauge, which might have been too small to aspirate the tenacious debris and pus, or the intent of the radiologist might have been to make a diagnosis rather than to treat the abscess.

Aspiration of a 7 x 6-cm abscess yielded 200 mL of fluid and resulted in a large residual abscess cavity that was irrigated with saline solution and redrained. The abscess partially resolved after months of antibiotic therapy, but it ultimately required a second aspiration and a surgical procedure. The last abscess drainage assessed resulted in a residual 2.0-cm fluid collection; the abscess continued to decompress through the nipple during the next 6 weeks, with the result being a smaller, partially solid abscess cavity. Six months later, this abscess resolved without further intervention.

	DISCUSSION

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Although peripheral breast abscess generally has been associated with mastitis and breast feeding, the results of our study and others (9) indicate that abscess is not uncommon in nonlactating women. Our study results show that abscesses smaller than 2.5 cm can be treated with aspiration and antibiotic therapy without recurrence if the abscess cavity is completely or almost completely drained. In abscesses larger than 3 cm, aspiration was used to make a diagnosis and obtain material for culture and sensitivity analyses, but it was not always successful in abscess drainage and treatment. Surgery or other decompression methods were required for definitive treatment in each case. In three of these cases, the small needle size probably affected the ability to aspirate pus from the abscess cavity. Because this was a retrospective study, it was difficult to assess the primary goal of the operator at the time of the drainage procedure for diagnosis, therapy, or both. Thus, the goal of the procedure may have accounted for the large residual abscess fluid collections. A larger needle or a 5-F catheter might have facilitated more complete drainage in these three cases and thus affected our results.

One of the patients had bilateral subareolar abscesses that failed to respond to drainage alone. The implications of a subareolar rather than peripheral breast abscess are important because the treatment for each of these two abscesses is different. The pathogenesis of the subareolar abscess is most commonly ductal ectasia, squamous metaplasia of the milk duct, chronic duct obstruction, and superinfection. The infected ectatic ducts are difficult to treat because antibiotic therapy alone fails to resolve the abscess, which tends to recur unless the infected, obstructed lactiferous duct is excised. The surgical excisional procedure is called microdochectomy, which has been described by Locker et al (10). The failure to treat the subareolar abscesses in our series should not have been unexpected, because surgery has been the definitive procedure for this problem (2,3,9,11). In these cases, US-guided percutaneous drainage might be used most appropriately as a temporizing procedure to allow resolution of the acute inflammation before subsequent surgical resection of the involved ducts.

On the other hand, in our study, the term "subareolar abscess" had a specific pathologic implication compared with "retroareolar abscess" (meaning posterior to the nipple). Nine of the 13 patients had retroareolar abscesses, but this common location does not automatically imply that the abscess will be chronic and require surgery. The subareolar abscess referred to in the surgical literature is a specific entity that should be considered if the abscess does not resolve by using conventional methods.

In cases of peripheral breast abscess associated with mastitis, radiologists should be aware of the types of infectious organisms and the necessity of a full, 10-day course of antibiotics after abscess drainage. Although peripheral breast abscesses generally have been treated with antistaphylococcal agents, the results of studies (9) indicate that anaerobic and microaerophilic species also may grow in peripheral abscesses in nonlactating women. This suggests that abscess specimens should be analyzed with both anaerobic and aerobic cultures and sensitivity testing. This has important implications for specimen collection, because the anaerobic culture may require more careful collection and attention in transport. On the other hand, the clinical results might be influenced by the stage of the abscess, because an acute abscess might respond more quickly to antibiotics compared with larger, chronic abscesses with thick rinds (early vs late suppurative phase).

The finding of neoplasm in two patients who were initially included in this study underscores the importance of cytology and possible follow-up imaging in the detection of cancer in women with suspicious breast masses and mastitis. Inflammatory cancer can masquerade as abscess, with the result being misdiagnosis (5).

In summary, the results of our study show that US-guided percutaneous needle drainage without indwelling catheter placement is feasible as a primary and definitive treatment for small peripheral breast abscesses if complete or near complete drainage is achieved. These results also show that success with this method is more common in abscesses with a maximum dimension smaller than 3 cm and after complete or near complete abscess drainage.

	Footnotes

 
Author contributions: Guarantors of integrity of entire study, D.M.I., G.W.H.; study concepts and design, D.M.I., G.W.H.; definition of intellectual content, D.M.I., G.W.H.; literature research, D.M.I., G.W.H.; clinical studies, D.M.I., G.W.H.; data acquisition and analysis, D.M.I., G.W.H.; manuscript preparation, editing, and review, D.M.I., G.W.H.

	References

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 

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