1. Present by Ekkasit MD.
Cystic Masses
of the Breast
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.

2. Introduction
Cystic lesions of the breast
– Most present between 30 and 50 years
of age.
– Asymptomatic or symptomatic ( nipple
discharge or a palpable mass)

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

4. Introduction
• On mammography
– Round, oval, or lobulated mass
– Circumscribed margins.
Obscured due to pericystic fibrosis.

5. Palpable left breast mass.

6. Palpable left breast mass.
Grade I intracystic papillary carcinoma.

7. Further Evaluations.
Compression views
• Improved assessment of lesion morphology
: shape, margins
• Associated findings such as calcifications
or distortion.
Additional imaging at different angles
• Permit localization three dimensionally in
the breast leading to targeted ultrasound.

8. Further Evaluations.
Ultrasound
• Differentiate cystic from
solid lesions.
Assessment of a mass seen on US
• shape, orientation, margin, boundary, inte
rnal echotexture, posterior acoustic
features, surrounding
tissue, calcifications, and vascularity.

11. Cystic Masses of the Breast
Simple cyst or not ?
Not simple cyst
imaging-guided intervention is
necessary to exclude a solid mass.

14. Simple Cysts
• Most common masses seen at
mammography.
• Result from dilatation and
effacement of theTDLU.
• Frequently multiple and fluctuate in
size on serial examinations.

15. Simple 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 2

16. Simple 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.

17. Simple cyst

18. (b)
Multiple cysts.
(a) Bilateral MLO mammograms
show multiple circumscribed
masses in both breasts.
(b) US images show anechoic
well-defined masses with
(a) smooth walls and posterior
acoustic enhancement.

19. Simple 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.

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

23. Complicated Cysts
• A cyst that meets all criteria of
simple cyst except contains
intermal echoes or fluid-fluid levels.

24. Complicated Cysts
• MRI:
– T1WI : Intermediate or high signal
because of proteinaceous contents or
blood products.
– T2WI : Variable depending on the cyst
contents.

25. Complicated cyst

26. Complicated Cysts
• Appropriate classification of
complicated cyst = BI-RADS 3
– Because there is only a 0.2% chance of
malignancy.
– Aspiration or short-interval follow-up
should be offered.

27. Complicated Cysts
• The differential diagnosis of a
complicated cyst:
– Galactocele
– Hematoma
– Oil cyst.
– Abscess.

28. Complex Cysts
• Thick walls
• Some discrete solid component
– Septa greater than 0.5 mm thick
– Mural nodules.

29. Complex Cysts
Differential diagnosis
Cyst with a mural Complex cyst:
nodule:
– Papillary tumor. – Hematoma.
– Atypical ductal – Galactocele.
hyperplasia.
– Abscess.
– DCIS
– Fat necrosis.
– Necrotic
neoplasm.

30. Simple cyst Complicated cyst Complex cyst
• Simple cyst • Galactocele • Galactocele
• Galactocele • Hematoma • Hematoma
• Hematoma • Oil cyst. • Fat necrosis.
• Oil cyst. • Abscess. • Abscess.
• Necrotic tumor.
• Papillary tumor.
• Atypical ductal
hyperplasia.
• DCIS

33. Galactocele
• Accumulation of milk distal to an obstruction in the
terminal ductal unit.
• Most galactoceles resolve with conservative
management.

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

35. Magnified lateral
MLO Complicated cyst
Mammographic and US images of left breast in lactating patient who
presented with palpable lump shows galatocele.

36. Fat contenting mass Complicated cyst
Galactocele
Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation

37. Hamartoma like mass
Complex cyst
Galactocele
Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation

38. Cystic mass with fat-fluid level galactocele
Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation

39. Galactocele
• Interventions:
– When the diagnosis is
uncertain.
– Occasionally, develop
superimposed infection.

41. Hematoma
• History of surgery, trauma or
anticoagulant therapy.
• The age of the blood products
determines the specific
appearance.

42. Hematoma
• 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.

43. 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.

44. • US shows a fluid-fluid level
containing mass without color
flow within the mass.
• NECT confirm hematoma.
BY Rathachai Kaewlai, M D

45. Hematoma
If the clinical history is suggested : BI-RADS 3.
If there is no history of recent trauma : BIRADS 4.

47. Fat 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.

48. Fat Necrosis
Mammography:
• Vague ill-defined asymmetries
• Spiculated masses
• Dystrophic calcifications.

49. Fat Necrosis
US: variable depending on the stage of the 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.

50. Fat Necrosis
MRI: variable depending on the stage of the 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.

51. Fat 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.

52. MAM: low-attenuation mass in
operative bed
US: complex avascular mass.

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

54. T2WI
Unenhanced T WI
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.
T WI with Gd

56. Breast 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.

57. Breast Abscess
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.

58. Breast Abscess
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.

59. 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

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

61. Breast Abscess
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.

63. Intracystic Papilloma
• Common cause of a cyst with a mural nodule.

64. Intracystic Papilloma
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.

65. Intracystic Papilloma
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.

66. Intracystic papilloma. Ultrasound in this -year-old woman with palpable lump in right
breast showed small vascular mural-based nodule within fluid-filled cyst.

67. Intracystic 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.

69. Necrotic Neoplasms
• Must always be considered in DDx of a
complex cyst.
• Necrosis most frequently develops in a
rapidly growing invasive ductal
carcinoma.

70. Necrotic Neoplasms
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.

71. Necrotic Neoplasms
MRI:
• An irregular or, less commonly, a
circumscribed mass.
• Heterogeneous or rim enhancement.

72. Multiple irregular masses with associated pleomorphic calcifications.

73. 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.

74. Summary
• Cystic lesions are commonly
encountered in breast imaging.
• Careful attention to the detailed
characteristics of the cystic mass and
correlation with patient history.

75. Cystic Masses of the Breast
Simple cyst or not ?
Not simple cyst
imaging-guided intervention is
necessary to exclude a solid mass.

76. Simple Cysts
– Sonographic criteria set forth by
Stavros:
• Anechoic.
• Well circumscribed with a thin echogenic
capsule.
• Increased through-transmission.
• Thin edge shadows.
– BI-RADS 2

78. Simple cyst Complicated cyst Complex cyst
• Simple cyst • Galactocele • Galactocele
• Galactocele • Hematoma • Hematoma
• Hematoma • Oil cyst. • Fat necrosis.
• Oil cyst. • Abscess. • Abscess.
• Necrotic tumor.
• Papillary tumor.
• Atypical ductal
hyperplasia.
• DCIS