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Ultrasound-guided drainage of breast abscesses: results in 151 patients

¹ Department of Radiology and ² Department of Surgery CE, Rigshospitalet, and ³ Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Denmark

	Abstract

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The aim of this paper is to describe the efficacy of ultrasound-guided drainage of breast abscesses with special attention to the risk of recurrence and the need for surgical treatment in a consecutive patient population. 151 patients, 89 with puerperal and 62 with non-puerperal breast abscesses, were treated with ultrasound-guided drainage, by needle or catheter under local anaesthesia. Follow-up punctures were performed at 2 or 3 day intervals until the clinical condition and ultrasound findings had improved. All patients were treated with oral antibiotics. Mammography was performed to search for underlying cancer. 86 (97%) out of 89 patients with puerperal abscesses and 50 (81%) out of 62 with non-puerperal abscesses recovered after the first round of ultrasound-guided drainage. One patient in each group had recurrence in loco but recovered after further ultrasound-guided drainage. 13 patients, 11 with non-puerperal and two with puerperal abscesses, underwent surgical excision of the abscess cavity or fistulas. Breastfeeding continued and 117 patients were treated as outpatients. The median number of follow up examinations in the ultrasound-department was four (range 1–10) for the group of patients with puerperal abscess and three (range 1–7) in the group of patients with non-puerperal abscess. The corresponding figure for the median number of punctures was for both groups one (range 1–6 and 1–4). There were no reports of newly diagnosed breast cancer in the 2 year follow-up period. This study supports the use of ultrasound-guided drainage in puerperal and non-puerperal breast abscesses. The method is less invasive than traditional surgery and has a high rate of success.

	Introduction

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Ultrasound-guided drainage has been described in smaller series as a treatment for breast abscesses, the treatment for which has traditionally been surgery or less frequently puncture without imaging guidance [1–5]. Ultrasound guided drainage is now widely accepted as first-line treatment. The aim of this study was to describe the efficacy of ultrasound guided drainage with special attention to resolution and to the risk of recurrence as well as the need for surgical treatment in a consecutive patient population.

	Materials and methods

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From 1 January 1998 to 31 December 2001, 248 patients were referred to the ultrasound department with clinical suspicion of new-developed breast abscess. In 87 (35%) of these patients breast abscess was excluded by ultrasound examination. The remaining 161 patients had a breast abscess. 10 of these 161 patients were not treated by ultrasound-guided drainage: five patients had abscesses which perforated spontaneously before treatment, three patients underwent surgery because the abscesses were too superficial and not suited for ultrasound-drainage with skin changes which required surgery for healing, one patient refused puncture under local anaesthesia and one 87-year-old patient had syncope before treatment was initiated and no further treatment was undertaken. The remaining 151 patients were treated with ultrasound-guided drainage of an abscess. They form the basis of the study.

The 151 patients that underwent ultrasound-guided drainage were all female, 89 had puerperal breast abscesses (median age 32 years, range 15–42 years), and 62 had non-puerperal abscesses (median age 42 years, range 15–72 years). None of the patients were undergoing treatment for other breast pathology.

Rigshospitalet is the centre for breast disease in central Copenhagen, covering a population of approximately 600 000 individuals. All patients with breast disease are referred to the clinic for breast surgery. If breast abscess is clinically suspected patients are referred to ultrasound for diagnosis and if possible for ultrasound-guided drainage with either a 0.8–1.2 mm needle or, if the cavity is larger than 3 cm, a 5.7 F (2 mm) one-step catheter. All punctures are performed under local anaesthesia. The procedure can be performed at any time in our institution when clinically indicated.

Follow-up ultrasound examinations are performed at 2–3 day intervals and if the abscess is still present, another puncture is performed or the catheter is left in place. Ultrasound follow-up ends when the clinical condition improves and two consecutive examinations have shown no residual abscess. The final examination is performed after the final puncture or removal of the catheter in the examination before. The catheter is cared for by the patient herself after instruction is given on the ward. The removal of a catheter requires clinical improvement of the local symptoms and no residual undrained fluid in the abscess visualized by ultrasound. All patients received oral antibiotic treatment; dicloxacillin 1 g three times a day in all patients and additionally metronidazole 0.5 g three times a day for non-puerperal abscesses. Patients allergic to penicillin receive erythromycin 500 mg three times a day. All 151 patients in this study followed this procedure.

In 2003 and 2004 the hospital case records were retrospectively reviewed. The following parameters were registered: patient data, details about drainage procedure and punctures, bacteriology and surgical data and possible recurrent abscess within 24 months. Clinical examination and mammography, ultrasound and where indicated ultrasound-guided biopsy, were performed within 3 months after the resolution of the abscess, mainly in the group of patients with non-puerperal breast abscesses. In January 2004 all 151 patients were followed in the register of the Danish Breast Cancer Group to see if any had been diagnosed with breast cancer within 24 months.

Statistical analyses were performed with SPSS for Windows 9.0 (SPSS Inc., Chicago, IL). Descriptives included numbers, percentage and range. Logistic regression analysis was first performed by univariate testing, where variables were tested based on literature and clinical experience. We planned to include variables reaching a significance level of <0.1 in univariate testing in a final multivariate logistic regression model. The outcome variable used was resolution after ultrasound-guided drainage, being defined as no recurrent abscess and no need for surgery.

	Results

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Patient data are given in Tables 1 and 2. 136 patients, 86 (97%) of the 89 patients with puerperal breast abscess and 50 (81%) of the 62 patients with non-puerperal breast abscess had no signs of remaining infection in the breasts after the first ultrasound-guided drainage treatment. 77 (87%) of the patients with puerperal breast abscess were treated as outpatients despite catheter drainage treatment. The catheters were cared for by the patients themselves after instruction and removed at the hospital after (median) 4 days (range 2–6 days).

Two patients, one patient in each group had a recurrent abscess (after 5 months and 10 months, respectively) but recovered after further ultrasound-guided drainage.

13 patients, two with puerperal and 11 with non-puerperal abscesses, underwent surgical excision of the abscess cavity. Two patients preferred surgery to ultrasound-guided drainage, one had pain after the abscess resolved and two other patients had an abscess that perforated during treatment. In six cases surgery was for a complicating fistula, one puerperal and five non-puerperal – two of the non-puerperal fistulae were present prior to commencement of treatment. One patient was not effectively treated with ultrasound-drainage, and one had pus in ectatic ducts and was difficult to treat with ultrasound-guided drainage.

The median number of follow up examinations in the ultrasound department was four (range 1–10) for the group of patients with puerperal abscess and three (range 1–7) in the group of patients with non-puerperal abscess. The corresponding figure for the median number of punctures was for both groups one (range 1–6 and 1–4). The two patients who had the most extensive treatment without reference to surgery needed six punctures and 10 ultrasound examinations each. Both patients had continuous improvement in both clinical condition and ultrasound findings which was why surgery was not performed.

The results of the univariate logistic regression analysis are presented in Table 3. Recovery was seen in 135 out of the 151 patients (87%). In this analysis only a puerperal history reached significance. A multivariate analysis was therefore not performed.

	Discussion

Top Abstract Introduction Materials and methods Results Discussion References

 
Ultrasound-guided drainage in combination with oral antibiotics was shown to be an effective treatment for breast abscess, especially for the group with puerperal abscesses. No other factors, including whether treatment was conducted using needle puncture and aspiration or catheter drainage, had any independent effect on the re-covery rate.

The high rates of recovery found in this study confirm previous studies, where recovery rates exceeding 90% using ultrasound-guided drainage have been reported [1, 4–6]. To our knowledge no previous study has included more than 30 patients. Treatment failure using ultrasound-guided drainage has been reported in cases where either the abscess has been larger than 3 cm in diameter or it was placed centrally in a subareolar position [1]. This study did not support these findings since neither size nor localization showed any independent effect on the recovery rate.

In some institutions the standard treatment still remains early incision under general anaesthesia combined with drainage tube insertion [7]. The side effects of this treatment include scarring and termination of breast-feeding [3]. Ultrasound-guided drainage causes less scarring, does not affect breast-feeding and does not require general anaesthesia or hospitalization [3]. Ultrasound-guided drainage is a less expensive procedure than surgery [9]. Based on our findings, ultrasound-guided drainage treatment should replace surgery as the first line of treatment in uncomplicated puerperal or non-puerperal breast abscess. Furthermore this technique is not difficult to master and the service can be provided on a 24 h basis.

In treatment resistant cases, where the abscess is unresponsive to the combination of repeated drainage and oral antibiotics, surgical treatment still has a role. It is unclear why some abscesses are unresponsive to treatment. Surgery is also needed in cases with superficial abscesses with skin changes. This can make a surgical excision necessary for healing. Surgery can also be necessary in special cases where other concerns such as suspicion of malignancy or the need for focus excision are important factors. Carcinoma of the breast may be confused with inflammatory conditions and thus pose a diagnostic problem [8]. We use early follow-up mammography within 3 months and when appropriate ultrasound-guided biopsy to exclude this diagnosis. In this study no patients had diagnosed breast cancer in the follow-up period. The number of patients included in this study is in our opinion not large enough to substantiate any statement about whether clinical mammography should be routinely undertaken. Likewise we have not found any reason to alter indications for mammography.

Needle puncture of lactating breasts has previously been associated with fistula formation [10]. In this study, six patients had a fistula in connection with a breast abscess. However only four of the 151 patients receiving ultrasound-guided drainage developed a fistula, of which only one had a puerperal abscess. Two of the six patients had a fistula before treatment started. These data indicate that ultrasound-guided drainage does not cause more fistula formation in puerperal than in non-puerperal abscesses.

In conclusion, this study supports the use of ultrasound-guided drainage in both puerperal and non-puerperal breast abscesses. The method is less invasive than traditional surgery and has a high rate of success.

Received for publication March 22, 2004. Revision received August 27, 2004. Accepted for publication October 4, 2004.

	References

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