Imaging Evaluation of Cystic and Solid Breast Lesions

Rodrigo Arrangoiz MS, MD, FACS, FSSO
Medial Lateral Oblique Mammogram.
Cranial Caudal Mammogram
  • The mammogram shows extremely dense breast tissue without other abnormality
Ultrasound imaging of a palpable lesion
  • Because no particle movement could be identified, 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:
      • 10 signs of malignancy on ultrasound:
        • Shadowing
        • Hypoechoic ecotexutre
        • Spiculation
        • Angular Margins
        • Thick echogenic halo
        • Microlobulation
        • Taller than wider
        • Duct Extension
        • Branching pattern
        • Calcifications
    • The three benign findings defined by Stavros are:
      • A purely hyperechoic lesion with no hypoechoic area larger than a normal duct or lobule
      • Elliptical, wider than tall, well-circumscribed and thin echogenic capsule
      • Gently lobulated, wider than tall, well-circumscribed and thin echogenic capsule
  • The ultrasound shows a round lesion that is neither elliptical nor gently lobulated, so even if a thin echogenic capsule could be identified, none of the 3 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
  • 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
      • 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
      • If there is no movement of particles:
      • A solid mass cannot be excluded
      • Although the lesion shown above would be considered BIRADS 3 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
Ultrasound appearance of a complex cyst with solid component as an intracystic mass
Ultrasound appearance of a complex cyst with the solid component as a thickened septum.
  • A “complex” cyst:
    • Has both cystic and solid components (Images)
    • The solid component may take the form of:
      • An intracystic mass or a thickened septum with a convex component
    • Biopsy is indicated to establish the diagnosis
    • If the lesion is large enough, 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.
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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