Cystic MassesCystic Masses

of of the Breastthe Breast

Present by Ekkasit MD.

R e s i d e n t s ’ S e c t i o n • P a t t e r n o f t h e M o n t h : AJR : 194, February 2010

By Neely Hines - Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School.

IntroductionIntroduction

Cystic lesions of the breastCystic lesions of the breast– Most present between 30 and 50 years of

age. – Asymptomatic or symptomatic ( nipple

discharge or a palpable mass)

IntroductionIntroduction

• On mammography– Round, oval, or lobulated mass– Circumscribed margins.

IntroductionIntroduction

• On mammography– Round, oval, or lobulated mass– Circumscribed margins.

Obscured due to pericystic fibrosis.

Palpable left breast mass.

Palpable left breast mass.G rade I intracystic papillary carcinoma.

Further Evaluations. Further Evaluations.

Compression viewsCompression views• Improved assessment of lesion morphology :

shape, margins• Associated findings such as calcifications or

distortion.

Additional imaging at different anglesAdditional imaging at different angles• Permit localization three dimensionally in the

breast leading to targeted ultrasound.

Further Evaluations. Further Evaluations.

UltrasoundUltrasound• Differentiate cystic from

solid lesions.

Assessment of a mass seen on US• shape, orientation, margin, boundary, internal

echotexture, posterior acoustic features, surrounding tissue, calcifications, and vascularity.

Cystic Masses of the BreastCystic Masses of the Breast

Simple cystSimple cyst or not ?or not ?

Not simple cystNot simple cystimaging-guided intervention is imaging-guided intervention is

necessary to exclude a solid mass.necessary to exclude a solid mass.

Simple CystsSimple Cysts

• Most common masses seen at mammography.

• Result from dilatation and effacement of theTDLU.

• Frequently multiple and fluctuate in size on serial examinations.

Simple CystsSimple Cysts• Mammographic findings:

– Circumscribed round or oval mass.

• Ultrasound: – Sonographic criteria set forth by Stavros:

• Anechoic.• Well circumscribed with a thin echogenic capsule.• Increased through-transmission.• Thin edge shadows.

– BI-RADS 2BI-RADS 2

Simple CystsSimple Cysts• MRI :

– Round, oval shape.

– Content : follow fluid signal on all sequences and do not enhance.

– However, the periphery of the cyst may enhance if there is surrounding pericystic inflammation.

Simple cyst

(a)

(b)

Multiple cysts.

(a) Bilateral MLO mammograms show multiple circumscribed masses in both breasts.

(b) US images show anechoic well-defined masses with smooth walls and posterior acoustic enhancement.

Simple CystsSimple Cysts

• Aspiration may be performed if :– Symptomatic.– The cyst prevents adequate compression

for mammography.

• Aspirated fluid is typically not sent for cytology except if it is bloody or the patient requests.

Simple CystsSimple Cysts

• The differential diagnosis for a simple cyst includes– Galactocele– Hematoma– Oil cyst.

Complicated CystsComplicated Cysts• A cyst that meets all criteria of simple

cyst except contains intermal echoes or fluid-fluid levels.

Complicated CystsComplicated Cysts

• MRI: – T1WI : Intermediate or high signal because

of proteinaceous contents or blood products.

– T2WI : Variable depending on the cyst contents.

Complicated cyst

Complicated CystsComplicated Cysts• Appropriate classification of

complicated cyst = BI-RADS 3BI-RADS 3 – Because there is only a 0.2% chance of

malignancy. – Aspiration or short-interval follow-up

should be offered.

Complicated CystsComplicated Cysts• The differential diagnosis of a

complicated cyst:– Galactocele– Hematoma– Oil cyst.– Abscess.

Complex CystsComplex Cysts

• Thick walls• Some discrete solid component

– Septa greater than 0.5 mm thick– Mural nodules.

Complex CystsComplex Cysts

Cyst with a Cyst with a mural nodule:mural nodule:– Papillary tumor.– Atypical ductal

hyperplasia.– DCIS

Complex cyst:Complex cyst:

– Hematoma.– Galactocele.– Abscess.– Fat necrosis.– Necrotic

neoplasm.

Differential diagnosisDifferential diagnosis

Simple cyst Complicated cyst Complex cyst

• Simple cyst• Galactocele• Hematoma• Oil cyst.

• Galactocele• Hematoma• Oil cyst.• Abscess.

• Galactocele• Hematoma• Fat necrosis.• Abscess.• Necrotic tumor.• Papillary tumor.• Atypical ductal hyperplasia.• DCIS

GalactoceleGalactocele

• Accumulation of milk distal to an obstruction in the terminal ductal unit.

• Most galactoceles resolve with conservative management.

GalactoceleGalactocele

• Mammographic images: – Typical - Circumscribed oval or round mass. – Late - Fat density layering on top.

• US:– Acute setting - a complicated cyst or anechoic fluid with thin

septa.– The galactocele ages - increases in complexity, fat–fluid levels. – Milk curdles - solid components within the cyst. – Finally - a solid echogenic mass.

The age of the milk products determines its mam-mographic and sonographic appearances.

MLO

Magnified lateral

Mammographic and US images of left breast in lactating patient who presented with palpable lump shows galatocele.

Complicated cyst

Galactocele.

Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation

Fat contenting mass Complicated cyst

Galactocele.

Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation

Hamartoma like mass

Complex cyst

Cystic mass with fat-fluid level galactocele.

Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation

GalactoceleGalactocele

• Interventions:– When the diagnosis is uncertain.– Occasionally, develop

superimposed infection.

HematomaHematoma

• History of surgery, trauma or anticoagulant therapy.

• The age of the blood products determines the specific appearance.

HematomaHematoma• US:

– A hyperacute hematoma : a simple cyst with internal echoes, which rapidly becomes a complicated cyst.

– Common appearance - a complex cyst with internal debris and a thick echogenic wall. – Avascular mural nodularity and septa.

• MRI: – Variable depending on the age of the blood products.– Peripheral enhancement reflects the healing process and inflammation.

Hematoma in woman who sustained thoracic trauma in motor vehicle collision.-Mixed density and partially circumscribed macrolobulated mass in upper central right breast.-US show complex cyst.

• US shows a fluid-fluid level containing mass without color flow within the mass.

• NECT confirm hematoma.

BY Rathachai Kaewlai, M.D.

HematomaHematoma

If the clinical history is suggested : BI-RADS 3.

If there is no history of recent trauma : BIRADS 4.

Fat NecrosisFat Necrosis• May be seen after surgery, RT, and trauma.

• Pathologically: Hemorrhage within fat, cystic degeneration, calcifications, fibrosis, scar formation.

• S&S: – Most often – asymptomatic– Occasionally - a tender palpable lump.

Fat NecrosisFat Necrosis

Mammography:Mammography:

• Vague ill-defined asymmetries• Spiculated masses• Dystrophic calcifications.

Fat NecrosisFat NecrosisUS: variable depending on the stage of the US: variable depending on the stage of the

process. process.

• Solid mass.• Complex mass.• Isoechoic or anechoic mass• Variable shadowing.• Increased echogenicity of the subcutaneous fat and

hyperechoic masses almost always indicates a benign finding.

• Varying degrees of fibrosis may give an appearance suspicious for malignancy.

Fat NecrosisFat NecrosisMRI: variable depending on the stage of the MRI: variable depending on the stage of the

process. process.

• Coarse calcifications may create signal voids.• Fibrosis can appear as distortion with or without

spiculation. • Variable signal on T1WI - substantial fibrosis.• Signal intensity changes of fat.• Lack of internal enhancement. • Mimic malignancy: Progressive-to-rapid contrast

enhancement and sometimes rim enhancement.

Fat NecrosisFat Necrosis

• Correlation of the MRI findings with mammography can be helpful when fat necrosis is a diagnostic consideration because most often there are characteristic findings that confirm the diagnosis.

• The findings of lack of internal enhancement on MRI and signal intensity changes of fat on MR images often can avoid biopsy and permit classification of this finding as BI-RADS 2.

MAM: low-attenuation mass in operative bedUS: complex avascular mass.

MAM : dystrophic and spherical calcifications in area of prior surgery.US: anechoic cyst.

U nenhanced T1 WI

T2WI

T1WI with Gd

MR images of third patient show low to intermediate signal intensity on unenhanced T1-weighted image, intermediate signal on T2-weighted sequence, and suspicious enhancement with washout kinetics after administration of gadolinium.

Breast AbscessBreast Abscess

• Breast abscess is a complication of mastitis.

• Most commonly in lactating women.

• Typically presentation: fever, chills, breast erythema, and tenderness.

• Imaging is used to differentiate between cellulitis or mastitis and abscess.

Breast AbscessBreast Abscess

US:US:• Oval, lobulated, or irregular-shaped cyst

with internal debris.• Thick hyperemic walls. • Motion of debris in the cavity.• Surrounding edema of the skin and

subcutaneous tissues.

Breast AbscessBreast Abscess

MRI:MRI:• Round or irregular mass.• T1WI - Intermediate SI centrally and a low-

signal peripheral rind that avidly enhances. • T2WI - High SI within the skin and breast

parenchyma.

Gray-scale image in breast-feeding patient shows ill-defined complex cyst with solid and hypoechoic elements with low-level internal echoes, consistent with abscess. Notice diffuse overlying skin thickening.

Image in another patient shows macrolobulated complex cyst with internal echogenic material and peripheral vascularity, also consistent with abscess.

Breast AbscessBreast Abscess

Treatment options:Treatment options:• Percutaneous drainage in conjunction with

antibiotic therapy. • Surgery is necessary for cases that are

refractory to antibiotics and percutaneous drainage

• for markedly multiloculated lesions.

Intracystic PapillomaIntracystic Papilloma

• Common cause of a cyst with a mural nodule.

Intracystic PapillomaIntracystic Papilloma

US:US: • Cyst with a mural-based nodule is often

seen.• In some cases, the solid component may

extend beyond the cyst toward the nipple.• The cyst may contain debris.

Intracystic PapillomaIntracystic Papilloma

MRI:MRI:

• Distended duct that may have high signal on T1WI if the duct contains proteinaceous debris or hemorrhage.

• A round filling defect may be seen within the duct.

• Papillomas enhance avidly with gadolinium.

- - 24Intracystic papilloma. Ultrasound in this year old woman with palpable lumpii iiiii iiiiii iiiiii iiiii iiiiiiii iiiii-iiiii iiiiii iiiiii iiiii-iiiii iiiii.

Intracystic PapillomaIntracystic Papilloma

• The diagnosis of benign papilloma cannot be reliably made with imaging.

• A biopsy must be performed, and the appropriate classification of this lesion is BI-RADS 4.

Necrotic NeoplasmsNecrotic Neoplasms

• Must always be considered in DDx of a complex cyst.

• Necrosis most frequently develops in a rapidly growing invasive ductal carcinoma.

Necrotic NeoplasmsNecrotic Neoplasms

US:US:

• An irregular mass with a central cystic component.

• Peripheral and some internal vascularity.

• BI-RADS 4 and the need for performing a core biopsy.

Necrotic NeoplasmsNecrotic Neoplasms

MRI:MRI:

• An irregular or, less commonly, a circumscribed mass.

• Heterogeneous or rim enhancement.

Multiple irregular masses with associated pleomorphic calcifications.

Two of masses show complex cystic lesions with areas of internal avascularity, consistent with necrosis, and other areas of internal vascularity, consistent with viable tumor.

.

SummarySummary

• Cystic lesions are commonly encountered in breast imaging.

• Careful attention to the detailed characteristics of the cystic mass and correlation with patient history.

Cystic Masses of the BreastCystic Masses of the Breast

Simple cystSimple cyst or not ?or not ?

Not simple cystNot simple cystimaging-guided intervention is imaging-guided intervention is

necessary to exclude a solid mass.necessary to exclude a solid mass.

Simple CystsSimple Cysts– Sonographic criteria set forth by Stavros:

• Anechoic.• Well circumscribed with a thin echogenic

capsule.• Increased through-transmission.• Thin edge shadows.

– BI-RADS 2BI-RADS 2

Simple cyst Complicated cyst Complex cyst

• Simple cyst• Galactocele• Hematoma• Oil cyst.

• Galactocele• Hematoma• Oil cyst.• Abscess.

• Galactocele• Hematoma• Fat necrosis.• Abscess.• Necrotic tumor.• Papillary tumor.• Atypical ductal hyperplasia.• DCIS