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Three Part Question

In [a patient with a breast abscess] is [needle aspiration as good as incision and drainage] in [achieving resolution and minimising recurrence]?

Clinical Scenario

A 28 year old lactating woman attends the emergency department with a history of pain in the breast. The patient has been taking antibiotics prescribed by her GP for 2 days without relief. On examination she has an abscess in her left breast. You wonder whether needle aspiration is an option or whether she needs formal incision and drainage.

Search Strategy

Medline 1966-01/04 using the OVID interface.
[breast abscess$.mp OR {(exp breast OR breast$.mp) AND (exp abscess OR abscess$.mp)}] AND [aspiration.mp OR exp needles OR needle$.mp]

Search Outcome

Altogether 63 papers were found, of which 6 were relevant to question and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tan SM and Low SC, 1998, Singapore	21 consecutive patients with breast abscess	Prospective case series	Clinical course	19 patients successfully treated by needle aspiration	No control Small study
			Recurrences	3
Schwarz RJ and Shrestha R, 2001, USA	30 patients with 33 breast abscesses treated by needle aspiration	Prospective case series	Clinical course	18 cases require only single aspiration. 9 cases required multiple aspirations, 6 cases required incision and drainage	No control Small study
Dixon JM, 1992, UK	18 consecutive patients with non-lactational breast abscesses Aspiration (10) vs local anaesthetic drainage (7) or both (1)	Clinical trial	Clinical course	All abscesses resolved within 2 weeks	Not randomised Small study
			Patient satisfaction	All patients expressed satisfaction
Hook GW and Ikeda DM, 1999, USA	13 patients undergoing ultrasonically guided breast abscess aspiration	Case series	Clinical course	8 abscesses resolved completely after aspiration. 5 were referred for surgical management	No control Very small study
Imperiale A et al, 2001, Italy	26 patients with 28 abscesses undergoing ultrasound guided fine needle aspiration and antibiotic injection	Case series	Clinical course (serial ultrasonography)	27 abscesses resolved over 7 weeks. One required surgical drainage	No control Small study
Leborgne F and Leborgne F, 2003, Uruguay	73 patients with breast abscesses undergoing sonographically guided aspiration and antibiotic instillation	Case series	Clinical course	38 cases cured after a single aspiration, 18 cured after 2 aspirations and 8 cured after multiple aspirations. Surgical rescue required in 3 cases and 6 patients refused a second aspiration	No control

Comment(s)

There are no good studies to answer the question. Most of the studies involved small numbers and are uncontrolled descriptions of case series. In these series the smaller the abscess the better is the outcome and lower is the recurrence rate. Needle aspiration may be more effective when combined with antibiotics – but again there are no controlled studies to allow us to conclude this definitely. A randomised controlled trial is needed.

Clinical Bottom Line

Needle aspiration may be an effective first treatment in small breast abscesses.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Tan SM, Low SC. Non-operative treatment of breast abscesses. Aust NZ J Surg 1998;68(6):423-424.
2. Schwarz RJ, Shrestha R. Needle aspiration of breast abscesses. Am J Surg 2001;182(2):117-119.
3. Dixon JM. Outpatient treatment of non-lactational breast abscesses. Br J Surg 1992;79:56-7.
4. Hook GW, Ikeda DM. Treatment of breast abscesses with US-guided percutaneous needle drainage without indwelling catheter placement. Radiology 1999;213:579-82.
5. Imperale A, Zandrino F, Calabrese M et al. Abscesses of the breast. US-guided serial percutaneous aspiration and local antibiotic therapy after unsuccessful systemic antibiotics. Acta Radiol 2001;42:161-5.
6. Leborgne F, Leborgne F. Treatment of breast abscesses with sonographically guided aspiration, irrigation and instillation of antibiotics. Am J Roentgenol 2003;181:1089-91.