Management of Suspected Breast Abscess in a Lactating Woman
The next step in management is B. Repeated aspiration, as ultrasound-guided needle aspiration (with or without ultrasound guidance) is the preferred first-line treatment for breast abscesses and has success rates of 82-96% in lactating women. 1, 2, 3, 4
Rationale for Aspiration Over Surgical Drainage
Needle aspiration combined with antibiotic therapy (which this patient has already started with flucloxacillin) is now considered the standard of care for breast abscesses, replacing traditional incision and drainage. 1, 3
In a study of 151 patients, 97% of puerperal (lactating) breast abscesses resolved with ultrasound-guided drainage, with most requiring only 1-2 aspirations (median of 1 puncture). 3
Another study demonstrated a 96% cure rate using aspiration with irrigation and local antibiotic instillation, with only 3 of 67 patients requiring surgical drainage after failed aspiration. 2
Aspiration without ultrasound guidance also shows an 82% overall cure rate, though success is higher when abscess volume is smaller (<4 mL vs >21 mL) and presentation is earlier (<5 days vs >8 days). 4
When Aspiration is Most Likely to Succeed
Smaller abscess volumes predict better outcomes with aspiration alone - this patient's 2x3 cm lesion is within the range typically amenable to aspiration. 4
Earlier presentation (within 5-8 days) correlates with higher aspiration success rates - this patient presenting at 6 days is within the optimal window. 4
The patient is already on appropriate antibiotic therapy (flucloxacillin), which is essential for treatment success alongside aspiration. 1, 2, 3
Aspiration Technique and Follow-up
Perform ultrasound-guided aspiration of the cystic lesion, sending aspirate for both culture AND cytology (to exclude rare underlying malignancy). 5
If more than 25 mm in size, consider local instillation of 1 gram of cephalosporin antibiotic after aspiration and irrigation. 2
Schedule repeat aspiration at 2-3 day intervals if clinical symptoms persist or ultrasound shows residual fluid collection. 3
Most patients require 1-2 aspirations total, with a median of 4 follow-up examinations. 3
When to Proceed to Incision and Drainage
Reserve incision and drainage (Option A) for aspiration failures only - typically after 2-3 failed aspiration attempts or if the abscess continues to enlarge despite aspiration and antibiotics. 1, 3
In the study by Dixon et al., only 3 of 22 abscesses (14%) required subsequent incision and drainage after failed aspiration. 1
Surgical drainage should also be considered if thick septations or loculations prevent adequate needle drainage. 3
Why Excisional Biopsy is NOT Indicated
Excisional biopsy (Option C) is not appropriate for acute infectious processes and would be considered only if malignancy is suspected after aspiration cytology or if an inflammatory cancer is clinically suspected. 5
While rare cases of squamous cell carcinoma can present as breast abscess, this occurs primarily in post-menopausal women, not lactating women. 5
The differential diagnosis includes galactocele, which also responds well to aspiration and does not require excision. 1
Critical Pitfalls to Avoid
Do not proceed directly to surgical drainage without attempting aspiration first - this causes unnecessary morbidity, scarring, and disruption of breastfeeding. 1, 3
Always send aspirate for cytology in addition to culture to exclude the rare possibility of underlying malignancy presenting as abscess. 5
Ensure adequate follow-up at 2-3 day intervals rather than waiting too long between aspirations, which can lead to treatment failure. 3
Continue breastfeeding from the affected breast if possible, as this aids in drainage and does not contraindicate aspiration treatment. 3