- A 42-year-old woman with no family history of breast cancer or previous breast problems presents for evaluation of a palpable mass she noticed 1 week ago:
- She does not perform regular self-examination and is not certain the lump is new
- A screening mammogram performed 3 months ago (Images) is unchanged from 1 year ago
- Ultrasound imaging of the palpable lesion is shown in Image 2:
- You alternately compress and relax the transducer and also increase the power of the beam, but you cannot demonstrate movement of particles within the mass.
- What would you recommend?
- You alternately compress and relax the transducer and also increase the power of the beam, but you cannot demonstrate movement of particles within the mass.
- The mammogram shows extremely dense breast tissue without other abnormality
- Palpable breast masses might be present in patients with a negative mammogram:
- This lesions can be obscured by the dense breast tissue
- Repeating a mammogram is unlikely to show the lesion
- Palpable breast masses might be present in patients with a negative mammogram:
- As is true for most breast lesions:
- Excision should not be the initial management:
- A diagnosis can be obtained with a needle
- Excision should not be the initial management:
- No particle movement could be identified on ultrasound of the breast nodule:
- One cannot be certain the mass is not solid:
- If solid, the sonographic mass has none of the 10 signs of malignancy, but it also does not meet any of the 3 strict benign criteria:
- It is round and neither elliptical nor gently lobulated, so even if a thin echogenic capsule could be identified:
- None of the three defined benign criteria are met
- When there is a thin echogenic capsule in a solid lesion that does not meet the other criteria:
- There is a 14% chance of malignancy:
- Therefore, further evaluation is necessary
- There is a 14% chance of malignancy:
- It is round and neither elliptical nor gently lobulated, so even if a thin echogenic capsule could be identified:
- If solid, the sonographic mass has none of the 10 signs of malignancy, but it also does not meet any of the 3 strict benign criteria:
- One cannot be certain the mass is not solid:
- Complicated cysts (Image) differ from simple cysts:
- Only with regard to internal echoes
- Complicated cysts are:
- Circumscribed and show posterior acoustical enhancement:
- But are not anechoic
- They are old cysts:
- That have gradually lost fluid through absorption:
- Leaving behind proteinaceous fluid, cholesterol crystals, blood, or other substances:
- That cause low-level internal echoes
- Leaving behind proteinaceous fluid, cholesterol crystals, blood, or other substances:
- That have gradually lost fluid through absorption:
- They can sometimes be difficult to distinguish from hypoechoic solid lesions
- If one can demonstrate swirling of particles within the mass:
- Either by “bouncing” the transducer against the lesion or increasing the power of the beam:
- The diagnosis of a cystic lesion can be made
- Either by “bouncing” the transducer against the lesion or increasing the power of the beam:
- If there is no movement of particles:
- A solid mass cannot be excluded
- Although the lesion shown above would be considered BIRADS III by many radiologists, and 6-month follow-up would perhaps be recommended:
- That approach might cause unnecessary anxiety:
- There would also be the possibility of diagnostic delay if the lesion turned out to be a well-circumscribed cancer:
- For these reasons, the best approach is to aspirate the lesion and try to evacuate the fluid
- Sometimes the “fluid” is the consistency of toothpaste and requires a 16- or even 14-gauge needle to evacuate it
- If nothing is obtained with a large bore needle:
- Core needle biopsy is indicated.
- There would also be the possibility of diagnostic delay if the lesion turned out to be a well-circumscribed cancer:
- That approach might cause unnecessary anxiety:
- Circumscribed and show posterior acoustical enhancement:
- A “complex” cyst has both cystic and solid components (Images)
- The solid component may take the form of an intracystic mass (Image) or a thickened septum with a convex component
- Biopsy is indicated to establish the diagnosis
- If the lesion is large enough (Image), biopsy can usually be obtained with a core device without vacuum assistance
- If the lesion is predominately cystic with a thickened, convex septum, percutaneous vacuum-assisted or surgical excision may be required because the lesion may not be visible after initial core needle targeting, resulting in incomplete sampling
- Vacuum-assisted sampling is usually adequate to establish a diagnosis and plan surgical therapy, if needed
- On the other hand, surgical excision of either of these complex cysts would give the pathologist the advantage of examining the entire specimen intact
- References:
- D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS® Atlas: Breast Imaging Reporting and Data System, 5th ed. Reston, VA: American College of Radiology; 2013.
- Berg WA, Sechtin AC, Marques H, Zhang Z. Cystic breast masses and the ACRIN 666 experience. Radiol Clin North Am. 2010;48(5):931-987.
- Stavros AT. Sonographic evaluation of breast cysts. In: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:276-350.
Rodrigo Arrangoiz MS, MD, FACS, FSSO 