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Breast Cyst
Breast Cyst
management
Authors: Christine Laronga, MD, FACS, Sharon Tollin, PhD, ARNP, AOCNP, Blaise Mooney, MD
Section Editors: Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C), Gary J Whitman, MD
Deputy Editor: Wenliang Chen, MD, PhD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2024. | This topic last updated: Apr 12, 2022.
INTRODUCTION
A breast cyst is a fluid-filled round or ovoid mass derived from the terminal duct
lobular unit (TDLU) ( image 1). Cysts begin as fluid accumulation in the TDLU
because of distension and obstruction of the efferent ductule [1]. (See "Breast
development and morphology", section on 'Lobule formation'.)
Breast cysts, which can present as a solitary mass or as multiple masses, usually
prompt women to seek medical attention because of the palpable mass or associated
pain or discomfort. A breast cyst may be first identified on a clinical or self-breast
examination or as a mammographic mass or density. Breast cysts may fluctuate in
size, number, and magnitude of symptoms.
The clinical features, diagnosis, and management of breast cysts are the focuses of
this topic. Information on evaluation and treatment of solid breast masses, both
benign and cancerous, can be found in other UpToDate topics:
● (See "Clinical manifestations, differential diagnosis, and clinical evaluation of a
palpable breast mass".)
● (See "Diagnostic evaluation of suspected breast cancer".)
● (See "Clinical features, diagnosis, and staging of newly diagnosed breast cancer".)
● (See "Overview of the treatment of newly diagnosed, invasive, non-metastatic
breast cancer".)
EPIDEMIOLOGY
The natural history of breast cysts consists of cyclic development and regression; 69
percent resolve within five years [5].
CLINICAL FEATURES
Acute enlargement of cysts may cause severe, localized pain of sudden onset.
Microcystic changes of the breast frequently cause pain and/or tenderness prior to
the onset of menses, and sometimes pain persists throughout the menstrual cycle.
(See "Breast pain", section on 'Cyclical breast pain'.)
Physical examination findings — Physical examination alone cannot definitively
distinguish between a benign cyst, benign solid mass, and malignancy. A large or
small breast cyst can be palpated as a smooth, firm, discrete, and frequently tender
mass. Cysts may present as a cluster of small masses or as an ill-defined mass. The
texture is variable, often described as similar to a grape, water balloon, or even hard
mass. Some, but not all, cysts have a sharp distinct border and are ballotable. (See
"Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable
breast mass", section on 'Physical examination' and "Clinical manifestations,
differential diagnosis, and clinical evaluation of a palpable breast mass", section on
'Benign'.)
Imaging — Breast cysts can be evaluated by several imaging studies. The choice of
the initial breast imaging modality depends on the woman's age, which is discussed
elsewhere. (See "Diagnostic evaluation of suspected breast cancer", section on
'Palpable breast mass'.)
Clustered microcysts and cysts with thin septa are subsets of simple cysts [6].
Clustered microcysts are a cluster of simple anechoic cysts, each smaller than 2 to 3
mm, without discrete solid components. Cysts with thin septa that are less than 0.5
mm in thickness are defined as simple cysts.
MRI — Magnetic resonance imaging (MRI) depicts a cyst as a round or oval sharply
defined mass ( image 7). A cluster of cysts is similarly depicted ( image 8). The
typical cyst will appear with bright, high-signal-intensity on T2-weighted fat-
suppressed images. After injection of gadolinium, a cyst appears as a filling defect,
sometimes with rim enhancement. If septations are present, they are nonenhancing
[19]. In a study evaluating complex cystic breast lesions with MRI, rim enhancement
was the dominant pattern in benign lesions [20]. By contrast, malignant lesions were
associated with heterogeneous contrast enhancement, type III kinetic curves,
diffusion restriction, and tall choline peaks.
Suspicious cystic lesions found incidentally on breast MRI should prompt further
evaluation with breast ultrasound. The indications and findings on MRI of the breast
are reviewed elsewhere. (See "Diagnostic evaluation of suspected breast cancer",
section on 'Breast MRI' and "MRI of the breast and emerging technologies".)
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Fat necrosis – Fat necrosis of the breast is a benign condition that most
commonly occurs as the result of breast trauma or surgery and can be
confused with a malignancy on physical examination. It may contain partially
liquified fat on the ultrasound assessment. Mammography may show a
calcified rim classic for fat necrosis. The diagnosis can be confirmed by a
diagnostic needle biopsy. (See "Overview of benign breast diseases", section on
'Fat necrosis'.)
• Galactocele – Galactoceles (milk retention cysts) are cystic collections of fluid,
usually caused by an obstructed milk duct. These present as soft cystic masses
on physical exam but are not tender and are not associated with systemic
findings. Ultrasound may show a complex mass. The diagnosis can be made on
the basis of the clinical history and aspiration, which yields a milky substance.
(See "Common problems of breastfeeding and weaning".)
• Oil cyst ( image 9) – An oil cyst contains a collection of liquified fat. If there is
any question on the ultrasound, an aspiration can be performed to confirm the
diagnosis. (See "Overview of benign breast diseases", section on 'Fat necrosis'.)
• Malignancy – A colloidal breast cancer or a cyst wall cancer may have a similar
appearance to a complicated or complex cyst on ultrasound, mammography,
and/or magnetic resonance imaging (MRI). Apocrine papillary carcinoma can
present as a complex cyst with a mural nodule on ultrasound [24,25]. The
diagnosis can be established by a diagnostic needle biopsy (preferred) or
excisional biopsy. (See "Diagnostic evaluation of suspected breast cancer".)
MANAGEMENT
Generally speaking, simple cysts, clusters of simple microcysts, and most complicated
cysts are BI-RADS 2 (benign), which does not warrant tissue diagnosis. Occasionally,
complicated cysts can be BI-RADS 3 and thus should undergo short-interval repeat
physical examination and imaging in six months. Complex cysts are BI-RADS 4 or 5
and should undergo ultrasound-guided core needle biopsy (CNB).
Simple cyst — A simple cyst is benign, and no further intervention is necessary [26-
28]. Clustered simple microcysts are also benign, and no further intervention is
required.
We do not excise simple cysts for any reason. Fine needle aspiration (FNA) of a simple
cyst is only performed for signs of infection or inflammation (red skin). In such cases,
FNA must be performed under real-time ultrasonographic guidance to assure
complete collapse of the cyst [29]. If the aspirated fluid is turbid, it should be sent for
culture, but not cytology, as cyst fluid will almost always contain atypical cells. Only
frankly bloody fluid should be sent for both culture and cytology. (See "Breast biopsy",
section on 'Cyst aspiration'.)
If the aspirated cyst does not completely collapse, the procedure can be converted to
an ultrasound-guided CNB to obtain a tissue diagnosis. Alternatively, if the FNA is
done by palpation alone or by ultrasound not performed by a radiologist, the best
practice would be to stop and get a diagnostic mammogram and diagnostic
ultrasound first, before pursuing a CNB.
Complicated cyst — Most complicated cysts are BI-RADS 2, which does not require
any further intervention. Occasionally, complicated cysts can be BI-RADS 3.
Complicated cysts classified as BI-RADS 3 should undergo repeat ultrasound imaging
and mammography (if the lesion was visualized on mammography) and clinical
examination in six months [12]:
● Worrisome changes (eg, increase in size, development of a solid component)
should be pursued by an image-guided CNB. (See "Screening for breast cancer:
Strategies and recommendations" and "Breast biopsy".)
● If the complicated cyst is downgraded to BI-RADS 2 on repeat imaging, the
woman should undergo clinical examination and imaging (ultrasound and
mammography) in another six months. As long as the latest imaging does not
classify the lesion as BI-RADS 3 or above, the patient does not require any further
intervention and can return to routine annual screening.
● If the complicated cyst remains BI-RADS 3 on repeat imaging, repeat clinical
examination and imaging should be continued every six months.
This option does require patient compliance. One study showed that 36 percent of
patients who were recommended to have short-term follow-up of cystic lesions did
not achieve two years of compliance [31]. For noncompliant patients or women
uncomfortable with follow-up, biopsy should be performed.
If the aspirated cyst does not completely collapse, further imaging (eg,
mammography) and CNB are required.
If the findings on imaging and CNB pathology are concordant and benign, follow-up
includes a clinical breast examination and imaging studies (breast ultrasound and
mammography) every 6 to 12 months for one to two years to document stability [30].
Any changes in the biopsied lesion or growth of the lesion should lead to rebiopsy or
excision [36,38,39]. A study of 156 patients who had a benign breast biopsy showed
that 13 percent required a subsequent biopsy within two years [39].
Benign histologic findings associated with complex cysts include a wide range of
diagnoses and should be treated appropriately [37,40]. (See "Overview of benign
breast diseases".)
The overall risk of a subsequent breast cancer is not increased for women with a
history of simple breast cysts [40,43,44]. In a retrospective review of 480 subsequent
breast cancer diagnoses among 14,602 women with benign breast biopsies, simple
cysts were not associated with subsequent breast cancer development [43].
For patients with complicated or complex cysts, the risk of a subsequent breast
cancer is related to the findings from the biopsy. As an example, mucocele-like lesions
are cystic breast lesions that are often associated with atypical hyperplasia. In one
study of 102 patients with mucocele-like lesions, 13 patients developed breast cancer
at a median follow-up of 14.8 years [45].
Persistent, rapidly recurring cysts may require close follow-up. Although rare, one
case report documented invasive ductal carcinoma in a simple cystic mass [46]. An
enlarging breast cyst with irregular and hypoechogenic vegetation growing on the
inner wall revealed a primary squamous cell carcinoma on biopsy [47].
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Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
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keyword(s) of interest.)
● Basics topics (see "Patient education: Common breast problems (The Basics)")
● Beyond the Basics topics (see "Patient education: Common breast problems
(Beyond the Basics)")