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1 Both authors: Breast Unit, Instituto de Radiología y Centro de Lucha contra el Cáncer, Pereira Rossell Hospital, B. Artigas 1550, Montevideo, Uruguay.
Received December 20, 2002;
accepted after revision April 9, 2003.
Address correspondence to Felix Leborgne, P. O. Box 6571, 11100 Montevideo,
Uruguay.
Abstract
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MATERIALS AND METHODS. Seventy-three patients with breast abscesses were seen from 1995 to 2001. Aspiration and irrigation were performed under sonographic guidance. Repeated aspiration was performed when deemed necessary. One gram of cephradine was injected into 29 abscesses measuring more than 25 mm.
RESULTS. Six patients refused further treatment after failure of the first aspiration and elected surgical drainage. Of the remaining 67 patients who completed treatment, 38 required one aspiration for cure, 18 required two aspirations, and eight required more than two aspirations. The treatment failed and surgical drainage was required in only three of the 67 patients completing treatment.
CONCLUSION. Ninety-six percent of patients completing treatment were cured with this procedure. Local instillation of antibiotics is probably beneficial.
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Imaging-guided (with sonography or CT) percutaneous treatment of purulent collections and placement of indwelling catheters in nonbreast sites have become increasingly popular since the 1980s. A more conservative approach for breast abscesses using percutaneous needle aspiration, irrigation of the cavity, instillation of local antibiotics, and systemic antibiotics, has also been facilitated with the introduction of high-resolution real-time sonography. It has been reported in the literature that abscesses larger than a mean of 21.5 mL [2] or 3 cm in diameter [3] treated by aspiration and irrigation without instillation of local antibiotics have a lower success rate than smaller abscesses. The purpose of this study is to review our experience in the treatment of breast abscesses using aspiration, irrigation, and instillation of antibiotics.
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Real-time sonography (Fig. 1A, 1B) was performed by a radiologist with a 7-13–MHz linear array transducer (Dynaview II, SSD-1700, Aloka, Tokyo, Japan). Patients with acute mastitis in whom a collection was not seen on sonography were excluded. The median long-axis diameter was 34 mm (range, 15–80 mm) as measured by the calipers on the sonogram.
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The procedure was performed on an outpatient basis. A 14-gauge needle was used for aspiration under sonographic guidance with a freehand technique. Local anesthesia was used at the puncture site. The use of 16-gauge needles or thinner is discouraged because they may fail to evacuate inspissated pus. The entry site of the needle was selected to avoid the area of skin thinning if present, where an abscess may drain spontaneously. The abscess was aspirated and the cavity was thoroughly irrigated with saline until the aspirate returned clear. Loculations were disrupted by irrigation. Aspirated material was sent for bacteriologic culture. Then 1 g of cephradine (Velocef, Bristol-Myers Squibb, Princeton, NJ) was instilled into abscesses that measured more than 25 mm in diameter. Oral cephradine, 500 mg three times a day, was also prescribed. Patients were scheduled for a follow-up sonographic examination a week later, and further aspirations were performed if deemed necessary. Patients were no longer followed up when clinical evidence of inflammation or residual collection was no longer seen on sonography. Patients who were nursing were encouraged to continue doing so.
Thirty-three (45%) of 73 abscesses yielded a sterile bacteriologic culture. The responsible organisms were confirmed to be Staphylococcus aureus in 42%, Proteus mirabilis in 5%, Escherichia coli in 3%, and Streptococcus organisms in 1%. Anaerobic organisms such as Streptococcus and Bacteroides species were found in 4% of abscesses.
No institutional review board approval was sought because our study was a survey of an existing clinical practice in our institution. Written informed consent was required.
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Two of the 67 patients who completed treatment were referred for surgical treatment after three and seven consecutive aspirations failed to cure their retroareolar abscesses, respectively. An additional patient, at the beginning of this experience, was referred to surgery after a failed attempt at aspirating inspissated pus through a 16-gauge needle. Fourteen-gauge needles were used thereafter. The resulting success rate of aspiration without resorting to surgical drainage was 96%. If the six patients who abandoned treatment after the first aspiration are included, a total of 64 (88%) of 73 abscesses were cured with the percutaneous procedure.
Intracavitary cephradine was injected into 29 of 30 abscesses measuring greater than 25 mm in diameter. The median volume of these abscesses was 25 mL, compared with a median of 4 mL for those not treated with intracavitary antibiotics. The success rate of abscess resolution in patients receiving intracavitary cephradine was 27 of 29, or 93%.
The cure rate stratified by the responsible organism was as follows: 27 (82%) of 33 with sterile cultures, 33 (97%) of 34 for S. aureus and anaerobic organisms, one of two for E. coli, and three of four for P. mirabilis.
No complications were observed in 62 of 64 patients successfully treated with aspiration, and no patients developed sequelae. The two remaining patients, who had spontaneous drainage through the skin during the conservative treatment, showed minimal residual scarring of the skin at this site. Treatment of these two patients, who presented with a preulcerative condition with skin thinning, was considered to be completely successful because surgery was avoided.
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Battle and Bailey [6], quoted by Uriburu [7], in 1923 first suggested that breast abscesses could be successfully treated with percutaneous aspiration of pus and irrigation of the cavity with Dakin's solution. In 1946, Florey et al. [8] first considered the possibility of daily aspiration of small abscesses and direct injection of penicillin soon after the drug became available at the end of World War II. Apparently both techniques fell into disuse shortly thereafter.
High-resolution real-time sonography is a unique means for diagnosing and evaluating the extent, site, size, and internal characteristics of breast abscesses. The possibility of using sonographically guided percutaneous aspiration has emerged as a valid alternative to surgical drainage. As far as we know, Karstrup et al. [9] first reported the successful use of this technique in 1990, soon followed by other investigators. More recently, Imperiale et al. [10] resurrected the local instillation of antibiotics (40–160 mg of gentamicin) after sonographically guided percutaneous aspiration in 26 patients with non-puerperal abscesses in whom systemic antibiotics failed, with only one failure requiring surgical drainage. Karstrup et al. [11] recommended continuous catheter drainage and irrigation of 20 puerperal abscesses using pigtail catheters that were placed for a median duration of 4 days. A 95% success rate was reported in that series. Forty-two percent of patients continued to breast-feed their infants.
In our study, a substantial number (45%) of aspiration cultures were sterile. Imperiale et al. [10] reported 23% of sterile cultures, which the authors attributed to previous antibiotic therapy.
Our study has shown that a high rate of success is achieved with percutaneous aspiration and careful irrigation of breast abscesses and that the placement of indwelling catheters is unnecessary. Most published series achieved similar results without requiring indwelling catheters. Lactating patients were encouraged to continue breast-feeding.
O'Hara et al. [12] reported an 85% cure rate of 22 abscesses, some of them aspirated without sonographic guidance. Schwarz and Shrestha [2] also reported aspiration without sonographic guidance plus oral antibiotics in 33 abscesses, with a resultant cure rate of 82%. Their success rate statistically correlated with a mean volume of pus at the first aspirate of 4.6 mL, compared with failures in abscesses with a mean volume of 21.5 mL. Hook and Ikeda [3] reported a 54% cure rate of 13 breast abscesses treated by aspiration and irrigation. The patients in whom treatment failed had an abscess of more than 3 cm in diameter. Dixon [13], however, reported successful aspiration of six lactating abscesses with a mean volume of 26 mL.
The rate of diffusion of cephradine through the abscess wall and its bioavailability at the abscess wall are not well known. Admittedly, bacteria are exposed to a higher concentration of antibiotic when the drug is injected into the abscess cavity and, consequently, a lower oral dose would be required [14]. Direct injection of antibiotics appears to be beneficial because the cure rate of large abscesses that were injected in our study was equivalent to that of small noninjected abscesses, which in the literature have shown a better prognosis. A definite answer to this question would require a randomized trial.
In conclusion, our study confirms previous reports that sonographically guided aspiration of breast abscesses without placement of indwelling catheters has become the treatment of choice. We have shown a success rate of 96% in patients completing treatment, with surgical drainage reserved for the few patients whose treatment failed. Local instillation of antibiotics is probably beneficial.
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