Cystic Breast Masses and the ACRIN 6666 Experience
Section snippets
Simple cysts
Simple cysts are epithelium-lined, fluid-filled, round or oval structures that are thought to occur secondary to obstructed ducts. The epithelium can be bland or apocrine type. The latter is a tall, cuboidal, secretory epithelium and can make the inner wall of the cyst appear fuzzy on high-resolution ultrasonography. Cysts can be isolated or diffuse and can occur in any quadrant. Ectopic breast tissue (tail of Spence) can extend into the axillary tail regions, but breast tissue and therefore
Complicated cysts: cysts with debris
Complicated cysts are masses that otherwise meet the criteria for simple cysts except that they are not anechoic, that is, they appear at least partially hypoechoic internally (Fig. 22). The internal echoes represent proteins from cell turnover, hemorrhage, or pus, and such proteins can be collectively termed debris.
Demographically, there is no difference between simple and complicated cysts with peak incidence for both at 35 to 50 years of age. In the ACRIN trial, participants with and without
Oil cysts
An oil cyst is a round or oval, liquid, fat-containing, encapsulated lesion. The cause is usually trauma, although the trauma can be so minor as to be unnoticed by the patient. Oil cysts can often occur after surgery and irradiation. Oil cysts are most commonly seen in superficial subcutaneous and subareolar tissues, which are the most mobile and most vulnerable regions to trauma. Ischemia can result in cell death and fat necrosis, particularly at the periphery (upper outer quadrant) of
Clustered microcysts
Clustered microcysts represent the terminal duct lobular unit, or a portion of it, where there has been cystic dilatation of individual acini (Fig. 43).1, 34 Clustered microcysts are a part of the spectrum of benign cystic change of the breast and can be lined with bland or apocrine metaplastic epithelium (see Fig. 43; Figs. 44 and 45). Stigmata of fibrocystic changes, with simple cysts, fibrosis, and adenosis, are also often present.
Clustered microcysts are most common in perimenopausal women
Complex cystic and solid masses
Complex cystic and solid masses are those with solid components such as a thick wall (≥0.5 mm), thick septations (≥0.5 mm), an intracystic mass, or solid masses with cystic areas. Such masses are uncommon but are suspicious for malignancy, BI-RADS 4, and merit biopsy. When malignant, the cystic portion can be due to areas of necrosis within a high-grade malignancy. As mentioned earlier, invasive cancers can mimic cysts or complicated cysts (see Figs. 7 and 30), although often slightly
Summary
Experience from ACRIN 6666 shows that simple and complicated cysts are far more common than previously recognized, even in postmenopausal women not on hormone replacement therapy. Based on review of the literature and the results of ACRIN 6666, the vast majority of asymptomatic complicated cysts (also known as cysts with debris) and clustered microcysts can be dismissed as benign findings provided strict criteria are used; any suspicious change should prompt biopsy. Complex cystic and solid
Acknowledgments
We thank Dr Ellen Mendelson, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA for thoughtful review, and we also thank the many contributors of images detailed in the figure legends. The authors also thank the many site investigators, research associates, and participants in the ACRIN 6666 protocol.
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Supported by Avon Foundation and NCI U01 CA79778, U01 CA80098.
Financial disclosures: WAB received elastography software from Siemens, Inc, a laptop computer and software from MediPattern, Inc, and has been a consultant to SuperSonic Imagine.