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Complex Cystic Breast Masses: Diagnostic Approach and Imaging-Pathologic Correlation¹

¹ From the Departments of Radiology (D.J.D., D.E.M., B.F.C.) and Pathology (G.M.C.), Baystate Medical Center–The Western Campus of Tufts University School of Medicine, 759 Chestnut St, Springfield, MA 01199. Recipient of a Certificate of Merit award for an education exhibit at the 2006 RSNA Annual Meeting. Received February 21, 2007; revision requested April 2 and received April 23; accepted May 3. All authors have no financial relationships to disclose.

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Infiltrating ductal carcinoma and ductal carcinoma in situ (DCIS) in a 44-year-old woman. (a) Mediolateral oblique mammogram shows a large mass with adjacent linear calcifications (arrow) in the upper part of the right breast. (b) US image demonstrates a type 1 complex cystic mass with a thick wall and thick septum. The diagnosis was based on the results of a core-needle biopsy.

 

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Infiltrating ductal carcinoma and ductal carcinoma in situ (DCIS) in a 44-year-old woman. (a) Mediolateral oblique mammogram shows a large mass with adjacent linear calcifications (arrow) in the upper part of the right breast. (b) US image demonstrates a type 1 complex cystic mass with a thick wall and thick septum. The diagnosis was based on the results of a core-needle biopsy.

 

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Oil cyst after reduction mammoplasty in a 23-year-old woman with a palpable mass in the region of postoperative scarring in the left breast. (a) Doppler US image shows a type 3 complex cystic mass without internal flow. (b) Tangential spot magnification mammogram, obtained after placement of an external marker, shows a well-circumscribed fat-density mass (arrows) with a characteristically benign appearance. Biopsy was not indicated.

 

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Oil cyst after reduction mammoplasty in a 23-year-old woman with a palpable mass in the region of postoperative scarring in the left breast. (a) Doppler US image shows a type 3 complex cystic mass without internal flow. (b) Tangential spot magnification mammogram, obtained after placement of an external marker, shows a well-circumscribed fat-density mass (arrows) with a characteristically benign appearance. Biopsy was not indicated.

 

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  Complicated cyst in a 46-year-old woman. (a) US image shows dependent intracystic echoes. (b) US image from a repeat examination with the patient in the left decubitus position shows mobility of the intracystic material. The cyst resolved completely after fine-needle aspiration, which yielded nonbloody material, and core-needle biopsy was not indicated.

 

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  Complicated cyst in a 46-year-old woman. (a) US image shows dependent intracystic echoes. (b) US image from a repeat examination with the patient in the left decubitus position shows mobility of the intracystic material. The cyst resolved completely after fine-needle aspiration, which yielded nonbloody material, and core-needle biopsy was not indicated.

 

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 4.  Papillary apocrine hyperplasia with atypical ductal hyperplasia. Doppler US image shows a type 2 complex cystic mass with flow within the solid component (arrow). The mass was diagnosed at core-needle biopsy, and the diagnosis was confirmed at surgical excision.

 

View larger version (168K): [in this window] [in a new window] [Download PPT slide]   Figure 5.  Papilloma in a 71-year-old woman. Power Doppler US image shows a type 2 complex cystic mass with flow within the solid components. The mass was diagnosed at core-needle biopsy.

 

View larger version (176K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Fibrocystic changes in a 59-year-old woman with a palpable breast mass. (a) Initial US image shows a cyst with a slightly thick wall (type 1). Fine-needle aspiration yielded nonbloody fluid. (b) Follow-up US image shows a residual ill-defined hypoechoic mass demarcated by electronic calipers. Histologic analysis of a core-needle biopsy specimen obtained with a 14-gauge automated device indicated cystic apocrine metaplasia and dense fibrous stroma with reactive stromal changes, findings consistent with cyst wall.

 

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Fibrocystic changes in a 59-year-old woman with a palpable breast mass. (a) Initial US image shows a cyst with a slightly thick wall (type 1). Fine-needle aspiration yielded nonbloody fluid. (b) Follow-up US image shows a residual ill-defined hypoechoic mass demarcated by electronic calipers. Histologic analysis of a core-needle biopsy specimen obtained with a 14-gauge automated device indicated cystic apocrine metaplasia and dense fibrous stroma with reactive stromal changes, findings consistent with cyst wall.

 

View larger version (179K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  Infiltrating ductal carcinoma in a 33-year-old woman with a palpable breast mass. (a) US image demonstrates a thick-walled complex cystic mass (arrows). (b) US image shows the mass during fine-needle aspiration, which yielded bloody fluid. The mass did not resolve completely. (c, d) US images obtained during core-needle biopsy, before (c) and after (d) firing of a 14-gauge automated device, show sampling of the small residual solid component. (e, f) Photomicrographs (original magnification, x100 in e, x400 in f; hematoxylin-eosin [H-E] stain) of a specimen obtained at core-needle biopsy reveal grade 3 infiltrating ductal carcinoma.

 

View larger version (175K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  Infiltrating ductal carcinoma in a 33-year-old woman with a palpable breast mass. (a) US image demonstrates a thick-walled complex cystic mass (arrows). (b) US image shows the mass during fine-needle aspiration, which yielded bloody fluid. The mass did not resolve completely. (c, d) US images obtained during core-needle biopsy, before (c) and after (d) firing of a 14-gauge automated device, show sampling of the small residual solid component. (e, f) Photomicrographs (original magnification, x100 in e, x400 in f; hematoxylin-eosin [H-E] stain) of a specimen obtained at core-needle biopsy reveal grade 3 infiltrating ductal carcinoma.

 

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 7c.  Infiltrating ductal carcinoma in a 33-year-old woman with a palpable breast mass. (a) US image demonstrates a thick-walled complex cystic mass (arrows). (b) US image shows the mass during fine-needle aspiration, which yielded bloody fluid. The mass did not resolve completely. (c, d) US images obtained during core-needle biopsy, before (c) and after (d) firing of a 14-gauge automated device, show sampling of the small residual solid component. (e, f) Photomicrographs (original magnification, x100 in e, x400 in f; hematoxylin-eosin [H-E] stain) of a specimen obtained at core-needle biopsy reveal grade 3 infiltrating ductal carcinoma.

 

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 7d.  Infiltrating ductal carcinoma in a 33-year-old woman with a palpable breast mass. (a) US image demonstrates a thick-walled complex cystic mass (arrows). (b) US image shows the mass during fine-needle aspiration, which yielded bloody fluid. The mass did not resolve completely. (c, d) US images obtained during core-needle biopsy, before (c) and after (d) firing of a 14-gauge automated device, show sampling of the small residual solid component. (e, f) Photomicrographs (original magnification, x100 in e, x400 in f; hematoxylin-eosin [H-E] stain) of a specimen obtained at core-needle biopsy reveal grade 3 infiltrating ductal carcinoma.

 

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 7e.  Infiltrating ductal carcinoma in a 33-year-old woman with a palpable breast mass. (a) US image demonstrates a thick-walled complex cystic mass (arrows). (b) US image shows the mass during fine-needle aspiration, which yielded bloody fluid. The mass did not resolve completely. (c, d) US images obtained during core-needle biopsy, before (c) and after (d) firing of a 14-gauge automated device, show sampling of the small residual solid component. (e, f) Photomicrographs (original magnification, x100 in e, x400 in f; hematoxylin-eosin [H-E] stain) of a specimen obtained at core-needle biopsy reveal grade 3 infiltrating ductal carcinoma.

 

View larger version (188K): [in this window] [in a new window] [Download PPT slide]   Figure 7f.  Infiltrating ductal carcinoma in a 33-year-old woman with a palpable breast mass. (a) US image demonstrates a thick-walled complex cystic mass (arrows). (b) US image shows the mass during fine-needle aspiration, which yielded bloody fluid. The mass did not resolve completely. (c, d) US images obtained during core-needle biopsy, before (c) and after (d) firing of a 14-gauge automated device, show sampling of the small residual solid component. (e, f) Photomicrographs (original magnification, x100 in e, x400 in f; hematoxylin-eosin [H-E] stain) of a specimen obtained at core-needle biopsy reveal grade 3 infiltrating ductal carcinoma.

 

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Intracystic papilloma. (a) US image shows a type 2 complex cystic mass. (b) US image obtained during a vacuum-assisted biopsy shows an 11-gauge needle probe (arrows) positioned deep to the mass. The diagnosis was established at vacuum-assisted biopsy.

 

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Intracystic papilloma. (a) US image shows a type 2 complex cystic mass. (b) US image obtained during a vacuum-assisted biopsy shows an 11-gauge needle probe (arrows) positioned deep to the mass. The diagnosis was established at vacuum-assisted biopsy.

 

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 9.  Intracystic papilloma in a 45-year-old woman. US image shows a type 2 complex cystic mass that contains a small intracystic papilloma suspended on a stalk. The mass was surgically excised. If a percutaneous biopsy had been performed, the solid part of the mass may have been difficult or impossible to target for biopsy after the fluid-filled portion was drained.

 

View larger version (96K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  Fibrocystic changes in a 45-year-old woman with a nonpalpable mass poorly depicted at mammography. (a) US image shows a type 1 complex cystic mass with thick septa. (b, c) Photomicrographs (original magnification, x40; H-E stain) of specimens from core-needle biopsy show apocrine metaplasia (b) and apocrine metaplasia with cyst formation (c).

 

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  Fibrocystic changes in a 45-year-old woman with a nonpalpable mass poorly depicted at mammography. (a) US image shows a type 1 complex cystic mass with thick septa. (b, c) Photomicrographs (original magnification, x40; H-E stain) of specimens from core-needle biopsy show apocrine metaplasia (b) and apocrine metaplasia with cyst formation (c).

 

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 10c.  Fibrocystic changes in a 45-year-old woman with a nonpalpable mass poorly depicted at mammography. (a) US image shows a type 1 complex cystic mass with thick septa. (b, c) Photomicrographs (original magnification, x40; H-E stain) of specimens from core-needle biopsy show apocrine metaplasia (b) and apocrine metaplasia with cyst formation (c).

 

View larger version (64K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.  Papilloma without atypia in a 62-year-old woman. (a) Craniocaudal mammogram shows a well-circumscribed mass (arrow) in the medial part of the breast. (b) Doppler US image demonstrates a type 3 complex cystic mass. (c) Photomicrograph (original magnification, x100; H-E stain) of a specimen from a core-needle biopsy shows intraductal papilloma without atypia, with apocrine metaplasia and microcalcifications.

 

View larger version (100K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.  Papilloma without atypia in a 62-year-old woman. (a) Cranio-caudal mammogram shows a well-circumscribed mass (arrow) in the medial part of the breast. (b) Doppler US image demonstrates a type 3 complex cystic mass. (c) Photomicrograph (original magnification, x100; H-E stain) of a specimen from a core-needle biopsy shows intraductal papilloma without atypia, with apocrine metaplasia and microcalcifications.

 

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 11c.  Papilloma without atypia in a 62-year-old woman. (a) Cranio-caudal mammogram shows a well-circumscribed mass (arrow) in the medial part of the breast. (b) Doppler US image demonstrates a type 3 complex cystic mass. (c) Photomicrograph (original magnification, x100; H-E stain) of a specimen from a core-needle biopsy shows intraductal papilloma without atypia, with apocrine metaplasia and microcalcifications.

 

View larger version (107K): [in this window] [in a new window] [Download PPT slide]   Figure 12a.  Lobular carcinoma in situ associated with multiple papillomas in a 45-year-old woman with mammographic findings of a mass and calcifications. (a) US image shows a type 2 complex cystic mass. (b) Radiograph of a specimen obtained at core-needle biopsy with an 11-gauge vacuum-assisted device shows calcifications. (c) Photomicrograph (original magnification, x100; H-E stain) of a core-needle biopsy specimen demonstrates an infarcted papilloma with calcifications. (d) Photomicrograph (original magnification, x40 [background], x400 [inset]; H-E stain) of the subsequent excisional biopsy specimen shows incidental lobular carcinoma in situ.

 

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 12b.  Lobular carcinoma in situ associated with multiple papillomas in a 45-year-old woman with mammographic findings of a mass and calcifications. (a) US image shows a type 2 complex cystic mass. (b) Radiograph of a specimen obtained at core-needle biopsy with an 11-gauge vacuum-assisted device shows calcifications. (c) Photomicrograph (original magnification, x100; H-E stain) of a core-needle biopsy specimen demonstrates an infarcted papilloma with calcifications. (d) Photomicrograph (original magnification, x40 [background], x400 [inset]; H-E stain) of the subsequent excisional biopsy specimen shows incidental lobular carcinoma in situ.

 

View larger version (159K): [in this window] [in a new window] [Download PPT slide]   Figure 12c.  Lobular carcinoma in situ associated with multiple papillomas in a 45-year-old woman with mammographic findings of a mass and calcifications. (a) US image shows a type 2 complex cystic mass. (b) Radiograph of a specimen obtained at core-needle biopsy with an 11-gauge vacuum-assisted device shows calcifications. (c) Photomicrograph (original magnification, x100; H-E stain) of a core-needle biopsy specimen demonstrates an infarcted papilloma with calcifications. (d) Photomicrograph (original magnification, x40 [background], x400 [inset]; H-E stain) of the subsequent excisional biopsy specimen shows incidental lobular carcinoma in situ.

 

View larger version (185K): [in this window] [in a new window] [Download PPT slide]   Figure 12d.  Lobular carcinoma in situ associated with multiple papillomas in a 45-year-old woman with mammographic findings of a mass and calcifications. (a) US image shows a type 2 complex cystic mass. (b) Radiograph of a specimen obtained at core-needle biopsy with an 11-gauge vacuum-assisted device shows calcifications. (c) Photomicrograph (original magnification, x100; H-E stain) of a core-needle biopsy specimen demonstrates an infarcted papilloma with calcifications. (d) Photomicrograph (original magnification, x40 [background], x400 [inset]; H-E stain) of the subsequent excisional biopsy specimen shows incidental lobular carcinoma in situ.

 

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 13a.  Fibroadenoma in a 48-year-old woman. (a) Craniocaudal mammogram shows an oval mass (arrow) in the lateral part of the breast. (b) US image demonstrates a type 1 complex cystic mass. (c) Photomicrograph (original magnification, x40; H-E stain) of a specimen from core-needle biopsy reveals fibroadenoma.

 

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 13b.  Fibroadenoma in a 48-year-old woman. (a) Craniocaudal mammogram shows an oval mass (arrow) in the lateral part of the breast. (b) US image demonstrates a type 1 complex cystic mass. (c) Photomicrograph (original magnification, x40; H-E stain) of a specimen from core-needle biopsy reveals fibroadenoma.

 

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 13c.  Fibroadenoma in a 48-year-old woman. (a) Craniocaudal mammogram shows an oval mass (arrow) in the lateral part of the breast. (b) US image demonstrates a type 1 complex cystic mass. (c) Photomicrograph (original magnification, x40; H-E stain) of a specimen from core-needle biopsy reveals fibroadenoma.

 

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 14a.  DCIS in a 64-year-old woman. (a) Mammogram shows an oval mass that corresponds to a palpable abnormality. (b) US image depicts a type 3 complex cystic mass. (c) Photomicrograph (original magnification, x100; H-E stain) of a specimen from core-needle biopsy reveals low-grade cribriform DCIS.

 

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 14b.  DCIS in a 64-year-old woman. (a) Mammogram shows an oval mass that corresponds to a palpable abnormality. (b) US image depicts a type 3 complex cystic mass. (c) Photomicrograph (original magnification, x100; H-E stain) of a specimen from core-needle biopsy reveals low-grade cribriform DCIS.

 

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 14c.  DCIS in a 64-year-old woman. (a) Mammogram shows an oval mass that corresponds to a palpable abnormality. (b) US image depicts a type 3 complex cystic mass. (c) Photomicrograph (original magnification, x100; H-E stain) of a specimen from core-needle biopsy reveals low-grade cribriform DCIS.

 

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