What is the role of incision and drainage in the management of breast abscesses and masses?

Updated: Jul 27, 2020
  • Author: Andrew C Miller, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Answer

Breast abscesses may be drained with incision and drainage (versus ultrasound-guided needle aspiration and irrigation). Historically, incision and drainage was considered the standard of care for abscesses. Although this method has a lower recurrence rate, it is more invasive than needle aspiration and frequently results in scarring with structural damage and poor cosmetic outcomes. [62] Fine-needle aspiration should be considered first-line therapy for abscesses smaller than 5 cm owing to its lower risks, followed by incision and drainage if recurrence occurs. [4] Surgical excision may be required for infected or obstructed lactiferous ducts and provides a lower rate of recurrence for nonpuerperal abscess and mastitis. [63, 8]

Ultrasound-guided needle aspirations are more successful on abscesses smaller than 3 cm and on puerperal abscesses. [64, 65, 66, 8] Loculations are associated with failure of resolution with aspiration, regardless of abscess volume. [67] Nonpuerperal abscesses have a higher rate of recurrence and often require multiple drainage attempts. [8] Regardless of the underlying organism, the need for repeat aspiration is common in patients treated with aspiration versus incision and drainage. [68] In a US cohort of 54 abscess cases treated with needle-guided aspiration, the median number of drainage procedures was 2 (interquartile range, 1.0-4.0), with 24% requiring 5 or more drainage procedures. [38]

Vacuum-assisted biopsy is a viable option for the management of lactational breast abscesses and has been associated with a shorter healing time than simple needle aspiration. [69] Furthermore, percutaneous catheter drainage may be considered for larger abscesses. [4, 70]

Ultrasonographic elastography with virtual touch tissue quantification (VTQ) is used to characterize breast lesions and to analyze the stiffness of glandular and subcutaneous fatty tissue in benign and malignant lesions. [71, 72] Acoustic radiation force impulse imaging is used to measure shear wave velocity (SWV), which reflects the stiffness of tissue. Tissue stiffness is measured within the lesion (internal SWV-SWVi) , in the boundary zone (SWVb), in normal‐appearing glandular tissue (SWVg), and in subcutaneous fatty tissue (SWVf). SWVs inside and at the edge of a breast mass are important for determining if they are benign or malignant. All types of SWVs were significantly higher in the malignant group than the benign group (P< 0.05).


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