docBreast Cysts Breast Cysts
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Breast Cysts Breast Cysts
Non-Simple Cysts in Breast Sonography Breast Cysts Interpretive difficulties – With improved resolution… Cindy Rapp BS, RDMS, FSDMS, FAIUM University of Colorado Hospital Denver, Colorado • Cysts which appeared to be simple on older lower resolution equipment, may appear to have internal echoes on newer higher resolution equipment. • Problem… we have been taught that any cyst with internal echoes must be classified as a “complex cyst” and that all complex cysts are worrisome. Breast Cysts Breast Cysts Acorn cyst Foam cyst Non-Simple Breast Cysts Breast Cysts occur far too commonly for: – biopsy – aspiration, or even – follow-up need more rationale approach complex / complicated breast cysts % of cysts that are complicated is increasing: – higher frequency – broader bandwidth – higher dynamic range increasing % caused by: – real echo producing internal structures – artifact simple cyst characteristics d c b if strictly met = BI-RADS 2 a anechoic * well-circumscribed ED ED ED thinly encapsulated * through transmission + thin edge shadows + ED enhanced * harmonics and compounding help + compounding may decrease Non-simple breast cysts simple cyst general rules meeting strict criteria (with gray fat) = BIRADS 2 the vast majority of non-simple breast cysts are within the spectrum of FCC. malignant cysts are exceedingly rare. the unusual malignant breast cyst is almost always obviously malignant. in individual cases: – – general rules are not necessarily reassuring a systematic evaluation is necessary Non-simple breast cysts - level 2 characterization systematic approach* 1) eliminate artifact – convert complex or indeterminate to simple 2) identify worrisome BIRADS 4b or 5 findings 3) if no BIRADS 4b or 5 findings, identify BIRADS 2 findings 4) if cannot identify BIRADS 2 findings, try to classify as BIRADS 3 5) if cannot identify BIRADS 3 findings, classify as BIRADS 4 * same as for mamms and US of solid nodules (no need to re-invent the wheel) non-simple breast cysts echo producing structures proteins globs cholesterol crystals fat globules WBC’s, RBC’s epithelial cells foamy macrophages apocrine cells PAM Simple Cyst complicated cyst simplified rules for BI-RADS 3 identical for those of solid nodule Proteinaceous/Lipid papilloma carcinoma Aprocine 1 layer complicated breast cysts artifactual echoes frequency, bandwidth, DR reverberations round or oval shape thinly encapsulated * no fibrovascular stalk * harmonics and compounding help clutter ringdown volume speckle averaging PAM complicated breast cyst simple with artifact vs. complicated harmonics (partial clearing) 1st -- eliminate artifact: z coded harmonics z real time compounding helps distinguish real from artifactual echoes simple with artifact vs. complicated pseudo-complicated vs. complicated real-time compounding increased echoes with harmonics non-compounded compounded complex breast cyst complex cyst septations systematic approach thick vs. thin 2nd -- look for BI-RADS 4 or 5 findings: thick isoechoic septations mural nodules fibrovascular stalk clustered microcysts complex cyst mural nodules BI-RADS 4 and 5 features major most mural nodules are caused by papillary apocrine metaplasia (PAM) features – angular margin where attached to wall – loss of capsule where attached to wall – protrusion beyond circular or oval shape – fibrovascular stalk on color Doppler – non-mobile with position changes growth of ICP mural nodules only a small percentage of mural nodules are caused by papilloma or papillary carcinoma growth of ICP mural nodules complex cyst mural nodules angular margins/loss of capsule at attachment reassuring suspicious complex cyst mural nodules complex cyst mural nodule fibrovascular stalk protrusion beyond cyst wall papillary apocrine metaplasia (PAM) – rarely develops fibrovascular stalk intracystic reassuring suspicious complex cyst mural nodule papilloma or CA – often easily demonstrable vascular stalk – take care not to compress to much – infarct frequently – lack of flow does not exclude ICPL complex cyst mural nodules fibrovascular stalk fibrovascular stalk single vessel complicated cyst mural nodule tumefactive sludge vs. ICPL FCC – a mixture of cystic, fibrous, & proliferative changes multiple vessel clustered microcystic appearance FCC – a mixture of which is FCC and which is HNG DCIS? Tabar cystic cystic, fibrous, and proliferative changes fibrous complex cyst internal echoes two main concerns: – tumor – infection 710 initial weeks exam later ––14 33 mmmm weeks later -- mm 50 US of breast cysts BI-RADS 3 signs of inflammation / infection * thick-wall inflamed & simple cysts in same patient uniform isoechoic wall thickening # fluid debris levels # hyperemia of cyst wall # * - Cannot distinguish between inflammation & infection by imaging alone (aspiration, gram stain, and culture required) - Wall thickening, hyperemia, and fluid-debris levels usually occur together # foamy macrophages differential dx for fibrosis = healed stage of inflammation uniform isoechioc no residual hyperemia of wall wall thickening inflamed PAM fluid-debris level fibrous complicated cyst fluid-debris level need to allow enough time for debris shift to occur (up to 5 min) mural nodule? mural nodule – NOT!!! orientation of vessel in thickened cyst wall correlates with etiology aspirate of inflamed cysts is purulent or bloody and purulent whether cyst is infected or blandly inflamed need gram stain and culture, but not cytology inflammation parallel to wall complicated breast cyst -systematic approach if no BIRADS 4-5 or BIRADS 3 infection findings neoplasm perpendicular to wall cysts that contain cholesterol crystals = BI-RADS 2 3rd -- look for BI-RADS 2 findings: simple cyst calcified lipid cyst cholesterol crystals thinly septated cyst fat - fluid levels clustered macrocysts milk of calcium skin cysts punctate wall Ca++ complex cysts with “streaming echoes”” cholesterol crystals must have thin, echogenic wall !!! cysts that contain cholesterol crystals = BI-RADS 2 complicated cysts with “color streaking” cholesterol crystals increasing gray scale power not as effective as color or power Doppler cysts that contain fat-fluid levels = BI-RADS 2 cysts that contain may take as long as 5 minutes to shift cholesterol crystals = BI-RADS 2 cholesterol crystals aspirated completely typical greenish – gray/brown FCC fluid FCC cytology – crystals seen on polarized light fat-fluid level cysts that contain sigmoid-shaped fat-fluid levels are: 1) obliquely oriented 2) in process of shifting cysts that contain ML mamm fat-fluid levels = “acorn” cysts = BI-RADS 2 cysts that contain milk of calcium = BI-RADS2 does not show it Tabar milk of calcium not milk, but tiny individual stones complicated cyst with milk of calcium Tabar CC view true ML view 15 or 20 stones usually necessary for classical “teacup” Can be difficult to keep small cysts in field of view when rolling pt milk of calcium – advantage US – can dx single stone sweep through multiple tiny cysts, each containing a single calculus cysts that contain circumferential wall calcification = BI-RADS 2 lipid (oil) cysts cysts that are clustered BI-RADS 2 on mamms & US (micro vs macrocystic TDLU) volume averaging BI-RADS 2 on mamms BI-RADS 3 or 4 on US often more definitively B9 on mamms Vs U/S cysts that arise from skin microcysts – BI-RADS 4a macrocysts – BI-RADS 3 cysts of skin origin sebaceous cyst appearances = BI-RADS 2 completely within skin stand-off partially within skin claw sign lesion completely within skin = BI-RADS 2 deep to skin gland neck sebaceous cysts cysts of skin origin cysts of skin origin main part of lesion deep to skin = BI-RADS 2 lesion partially within skin = BI-RADS 2 look for “claw sign” of skin wrapping around lesion sebaceous cysts look for gland neck passing to skin surface sebaceous cysts complicated breast cyst systematic approach 4th -- look for BI-RADS 3 findings: z fluid-debris level z uniform wall thickening acorn cyst foam cyst Jensen – UC Davis complex breast cyst level 2 characterization indeterminate cyst/solid subtle differences between solid nodules & foam cyst systematic approach 5th -- deal with indeterminate cyst/solid lesions try to clear internal artifact look for internal blood vessel assume solid and characterize attempt to aspirate Breast Cysts Color Doppler indeterminate cyst/solid assume solid and level 2 characterization usually has no BI-RADS 4 or 5 characteristics usually has BI-RADS 3 characteristics – round or oval shaped – thinly encapsulated * – enhanced through transmission * harmonics and compounding may help indeterminate cyst/solid attempt to aspirate (3 indeterminate cyst/solid aspiratability not predictable possibilities, not predictable) – completely non-aspiratable – partially aspiratable – completely aspiratable completely aspiratable “foam” or “gel” cyst indeterminate cyst/solid non-aspiratable, needle rocks internally needle rocked anteriorly needle rocked posteriorly indeterminate cyst/solid non-aspiratable – needle fixed internally indeterminate cyst/solid non-aspiratable until needle rocked internally failed aspiration can become FNA proteinaceous gel gel or foam in cork P.A.M. Rosen multiple different types of complex cysts frequently present in same breast complex breast cyst systematic approach 6th -- if cannot classify as BI-RADS 2 or 3... ...must classify as BI-RADS 4a non-simple breast cysts summary % of all cyst complex increasing complicated gold standard fuzzy use mamms & solid nodule algorithm use BIRADS categories if BIRADS 4a need histology if inflamed need aspiration and culture Thank-you
