Complex cystic and solid breast mass
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A complex cystic and solid breast mass also knowns as a complex breast cyst is a morphological type of breast cyst along with simple breast cysts and complicated breast cysts. Complex breast cysts are defined as cysts with thick walls, thick septa, intracystic masses, or other discrete solid components.
The currently preferred term for complex breast cysts is complex cystic and solid mass to avoid confusion with a complicated cyst. 9
Breast cysts are extremely common and are present in most women over 40 years old. Breast ultrasound allows its detection and the correct diagnosis of cyst has been reported to be almost 100%.
5% of breast ultrasound examinations report complex cyst.7
Complex breast cysts have a malignancy rate of 0.3% among breast neoplasms, it still has had a substantial probability of being malignant (23% and 31% in 2 series). 7
Complex breast cysts are associated with a variety of benign, atypical, and malignant pathological diagnoses, including fibrocystic changes, intraductal papilloma, abscess, hematoma, fat necrosis, fibrocystic mastopathy, phyllodes tumor, papilloma atypical ductal hyperplasia (ADH), ductal carcinoma in situ (DCIS), and infiltrating ductal carcinoma. 8
The presence of a thick wall, thick septae, or intracystic mass is characteristic of complex breast cysts 2. The majority show posterior acoustic enhancement due to the cystic component 5. The margin may be macro- or microlobulated, indistinct, or even irregular.
Depending on the ultrasonographic appearance complex breast cysts can be categorized into four categories using criteria adapted from Berg et al:
type I, masses with a thick wall (>0.5 mm) or thick septa (>0.5 mm) PPV for malignancy 7.1% 8
type II, masses of an intracystic type with one or more discrete solid mural lesions within a cyst PPV for malignancy 16.7%
type III, masses containing mixed cystic and solid components with the cystic portion occupying at least 50% of the mass PPV for malignancy 61.1%
type IV, masses that were predominantly (at least 50%) solid with eccentric or central cystic foci PPV for malignancy 44.8% 8
At ultrasound, breast cysts are categorized as simple, complicated, or complex. Appropriate categorization is important because the management of each type differs.
Studies have demonstrated the importance of appropriate categorization of complex breast cysts by using Berg criteria and describe other sonographic findings such as lesion size greater than or equal to 2 cm, the absence of circumscribed margins, RI greater than or equal to 0.7, and axillary abnormal nodes are significant predictors of malignancy. 8
Treatment and prognosis
Some authors find that the complex cystic lesions have 23% up to 31% risk of malignancy 4, while others estimate the risk as 0.3% 4. The former consider the complex breast cyst as intermediate BIRADS IVb lesions, while the latter consider them to be BIRADS IVa lesions 4.
The decision whether any interventional technique should be therefore guided by a clear indication and should be compatible with the patient's history and the result of mammography 4. The radiologist should choose the appropriate measure from the following alternatives:
fine-needle aspiration (FNA)
- FNA is the first interventional procedure that should be performed when there it is difficult to differentiate between a complicated cyst and a predominantly cystic complex mass
- purulent fluid suggests an inflammatory lesion and should be assessed by microbiological analysis, while hemorrhagic fluid raises the possibility of malignancy and should be analyzed cytologically
- assessing the lesion after aspiration is important to depict the solid component. if a solid component remains, core biopsy should be performed in the same session 4
- core biopsy should be the first intervention if there is a proven solid component associated with a suspicious finding in the mammogram (e.g. micro-calcification or architectural distortion) 4
Moving the patient to decubitus position is useful to differentiate the solid masses from thick debris 4. If the echogenic component is mobile it represents debris, pus, or a clot. If the echogenic component is immobile, it may represent either a true intracystic mass or debris adherent to the cyst wall.
- 1. Venta LA, Kim JP, Pelloski CE et-al. Management of complex breast cysts. AJR Am J Roentgenol. 1999;173 (5): 1331-6. AJR Am J Roentgenol (abstract) - Pubmed citation
- 2. Doshi DJ, March DE, Crisi GM et-al. Complex cystic breast masses: diagnostic approach and imaging-pathologic correlation. Radiographics. 2007;27 Suppl 1 : S53-64. doi:10.1148/rg.27si075508 - Pubmed citation
- 3. Paredes ES. Atlas of mammography. Lippincott Williams & Wilkins. (2007) ISBN:0781764335. Read it at Google Books - Find it at Amazon
- 4. Athanasiou A, Aubert E, Vincent Salomon A, Tardivon A. Complex cystic breast masses in ultrasound examination. (2014) Diagnostic and interventional imaging. 95 (2): 169-79. doi:10.1016/j.diii.2013.12.008 - Pubmed
- 5. Berg WA, Sechtin AG, Marques H, Zhang Z. Cystic breast masses and the ACRIN 6666 experience. (2010) Radiologic clinics of North America. 48 (5): 931-87. doi:10.1016/j.rcl.2010.06.007 - Pubmed
- 6. Houssami N, Irwig L, Ung O. Review of complex breast cysts: implications for cancer detection and clinical practice. (2005) ANZ journal of surgery. 75 (12): 1080-5. doi:10.1111/j.1445-2197.2005.03608.x - Pubmed
- 7. A highly aggressive invasive ductal carcinoma from a complex cystic breast mass and BI-RADS assessment: A case report. (2018) Medicine. 97 (50): e13740. doi:10.1097/MD.0000000000013740 - Pubmed
- 8. Jin‐Peng Yao, Yu‐Zhi Hao, Qing Chang, Cheng‐Yun Geng, Yu Chen, Wen‐Peng Zhao, Yan Song, Xiang Zhou. Value of Ultrasonographic Features for Assessing Malignant Potential of Complex Cystic Breast Lesions. (2017) Journal of Ultrasound in Medicine. 36 (4): 699. doi:10.7863/ultra.16.05012 - Pubmed
- 9. T. Díaz Antonio, G. Díaz Córdoba, M. D. M. García Gallardo, G. Garrido Ruiz, J. Irigoyen Oyarzábal, E. Pardo Susacasa, M. Acebal Blanco, L. Pérez Villa.Complex cystic and solid mass. Diagnostic management and anatomopathological correlation. ECR 2019 / C-3007 https://dx.doi.org/10.26044/ecr2019/C-3007