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Cystic Lesions of the Breast: Sonographic-Pathologic Correlation¹

¹ From the Department of Radiology (W.A.B., C.I.C.), Greenebaum Cancer Center (W.A.B.), and Department of Pathology (O.B.I.), University of Maryland Medical Center, 419 W Redwood St, Suite 110, Baltimore, MD 21201. From the 2001 RSNA scientific assembly. Received May 31, 2002; revision requested June 27; final revision received September 23; accepted September 30. Address correspondence to W.A.B. (e-mail: waberg@umaryland.edu).

View larger version (169K): [in a new window]   Figure 1. Complicated cyst with inflammatory changes. Transverse sonogram (10 MHz) of palpable mass obtained in a 53-year-old woman demonstrates a well-defined mass with homogeneous mobile low-level internal echoes and posterior acoustic enhancement (arrows). Aspiration yielded benign cyst with inflammatory changes.

View larger version (182K): [in a new window]   Figure 2. Complicated cyst, apocrine metaplasia. Radial sonogram (7.5 MHz) obtained in a 43-year-old woman shows mobile debris with a fluid-debris level (arrow) in a symptomatic cyst that otherwise met the criteria of simple cyst. Aspiration yielded apocrine metaplasia.

View larger version (147K): [in a new window]   Figure 3. Cyst with thin septations. Transverse sonogram (7.5 MHz) obtained in a 48-year-old woman shows a large cyst with thin (<0.5 mm) septations (arrowheads) that otherwise met the criteria for a simple cyst. This finding may represent the continuum of the spectrum from apocrine metaplasia as the acini fuse. Because it was large and tender, the cyst was aspirated to complete resolution, and results of cytologic examination yielded benign cyst contents. This recurred at 1-year follow-up.

View larger version (181K): [in a new window]   Figure 4. Clustered microcysts, apocrine metaplasia. Radial sonogram (10 MHz) obtained in a 50-year-old woman shows an incidental aggregate of tiny cystic foci (arrowheads) without a discrete solid component. In our experience, these sonographic features have been shown to correspond to benign breast disease, such as apocrine metaplasia, or fibrocystic changes without apocrine metaplasia. At histopathologic examination of the 14-gauge CNB specimen, dilated acini were demonstrated, lined by apocrine metaplastic epithelium. We now classify such nonpalpable lesions as probably benign with a 6-month follow-up.

View larger version (184K): [in a new window]   Figure 5. Thick-walled cystic mass, IDC grade 3. Radial sonogram (10 MHz) of a palpable mass obtained in a 43-year-old woman demonstrates an indistinctly marginated centrally cystic mass with a thick wall (arrows). Cytologic finding of the sonographically guided bloody aspirate of the cystic component was suggestive of malignancy, and CNB of the residual solid component yielded IDC, grade 3. The lesion resolved after neoadjuvant chemotherapy, and the site was difficult to identify for excision. Clip placement is advocated if the lesion is subtle or neoadjuvant chemotherapy is planned.

View larger version (190K): [in a new window]   Figure 6a. IDC (medullary type) with thick wall and thick septations. (a) Radial sonogram (7.5 MHz) of a palpable mass obtained in a 46-year-old woman demonstrates a thick-walled (arrows) cystic mass with thick septations (arrowheads). Posterior acoustic enhancement is present. The margins appear indistinct. (b) Mammographically, this was a new, partially circumscribed, and partially indistinctly marginated mass (arrow) in a patient with multiple bilateral circumscribed masses due to fibroadenomas and a cyst. Sonographically guided CNB with a 14-gauge needle and subsequent excision confirmed IDC grade 2, medullary type.

View larger version (104K): [in a new window]   Figure 6b. IDC (medullary type) with thick wall and thick septations. (a) Radial sonogram (7.5 MHz) of a palpable mass obtained in a 46-year-old woman demonstrates a thick-walled (arrows) cystic mass with thick septations (arrowheads). Posterior acoustic enhancement is present. The margins appear indistinct. (b) Mammographically, this was a new, partially circumscribed, and partially indistinctly marginated mass (arrow) in a patient with multiple bilateral circumscribed masses due to fibroadenomas and a cyst. Sonographically guided CNB with a 14-gauge needle and subsequent excision confirmed IDC grade 2, medullary type.

View larger version (172K): [in a new window]   Figure 7. Thick-walled cystic mass with thick septations, IDC grade 3. Transverse sonogram (10 MHz) obtained in a 35-year-old woman shows a cystic mass with posterior acoustic enhancement, thick wall, and thick septations (arrowheads). Aspiration yielded bloody fluid, and CNB findings of the residual solid component yielded IDC grade 3.

View larger version (179K): [in a new window]   Figure 8. Thick-walled complicated cyst, abscess. Radial sonogram (10 MHz) obtained in a 48-year-old woman shows a cystic mass with thick wall (arrows), posterior acoustic enhancement, and internal echoes that were mobile, with fluid-debris level (arrowhead) near the nipple. The surrounding tissue shows increased echogenicity compatible with edema. The mass was tender and palpable and was therefore aspirated to resolution, yielding pus.

View larger version (192K): [in a new window]   Figure 9. Intracystic mass, intracystic papillary DCIS. Radial sonogram (10 MHz) of a palpable mass obtained in a 36-year-old woman revealed a well-defined mass with a discrete solid component (arrow). Sonographically guided CNB yielded atypical ductal hyperplasia with papillary features. Excisional histopathologic examination revealed intracystic papillary DCIS. Atypical papillary lesions observed at CNB should be excised due to a 30% risk of malignancy at excision (39-41).

View larger version (188K): [in a new window]   Figure 10. Intracystic mass with thick septations, infiltrating and intraductal cribriform carcinoma. Transverse sonogram (7.5 MHz) of a palpable mass obtained in a 77-year-old woman shows a complex mixed cystic (C) and solid (S) mass. Excision showed infiltrating and intraductal cribriform carcinoma.

View larger version (156K): [in a new window]   Figure 11. Complex mass, galactocele. Transverse sonogram (7.5 MHz) of palpable mass occupying most of the breast obtained in a 18-year-old woman shows a complex cystic (C) and solid (S) mass. Aspiration was performed for symptomatic relief, yielding 250 mL of breast milk. The solid components were due to intervening normal breast tissue with extensive galactocele.

View larger version (195K): [in a new window]   Figure 12. Predominantly solid mass with eccentric cystic spaces, IDC grade 3. Transverse sonogram (10 MHz) of a palpable mass obtained in a 36-year-old woman with prior contralateral cancer 2 years earlier shows lobulated hypoechoic mass with eccentric cystic spaces (arrowheads). Findings of fine-needle aspiration (at an outside institution) showed atypical cells but were nondiagnostic. Gadolinium-enhanced breast magnetic resonance (MR) imaging demonstrated a rim-enhancing mass that was highly suggestive of malignancy. On the basis of MR imaging findings, the patient was referred for excision and sentinel node biopsy, which revealed IDC grade 3.