breast imaging, cyst, US, MRI, biopsy, fine needle aspiration, pathology

1. Breast cysts
Benign or malignant
Jean Yves Seror
Centre duroc
Paris

2. Breast Cysts
Benign or malignant
The diagnosis under imaging ULTRASOUND is very often sufficient :
• Current ultrasound classification systems are based on morpho-
structural aspects only
• Technical aspect: B Mode, Focale area, harmonic and compound mode, Color
Doppler , elastography
• Operator dependant : technique and interpretation +++
• Diagnosis accuracy : 96 to 100%
Neo formation of a cavity with a liquid content covered with a proper
cloating : epithelium
Starting point :
Duct lobular unit

3. Clinical
Diagnosis
• Prevalence : 37% to 90% accordingly to the age
• Palpable lesion from 35 years up to the menopause (in the
absence of hormonal treatment for the menopause)
• Their development is very often hormone-dependent and
punctuated by the menstruation .
• frequently ASYMPTOMATIC, casually discovered during an
ultrasound exam.
• The symptoms : the palpation or self palpation of a mass in the
breast, very often soft, renitent and mobile, sensitive and sometimes
painful, which can grow bigger just before menstruations, symptoms
for which an ultrasound exam has been prescribed. ( Cyst after stress)
Breast Cysts
Benign or malignant

4.
• Mammography
:
no
specific
• Opacity
in
the
mass,
regular
borders
some;mes
festooned
or
with
lobulated
borders
.
• Associa;on
with
microcalcifica;ons
(a
peripheral
arciform
calcifica;on
leads
toward
a
cyst
diagnosis).
• Associa;on
with
architectural
abnormali;es
• Tomosynthesis
:
best
visibility
of
the
borders
(+/-­‐)
Diagnosis

6. Classification de Y‐W CHANG 2007
Chang YW, Kwon KH, Goo DE, Choi DL, Lee HK, Yang SB.
Sonographic differentiation of benign and malignant cystic
lesions of the breast. J Ultrasound Med 2007;26:47-53
Stavros
Radiology
1995
Berg
Radiology
2003
BI-­‐RADS ®
ACR
2010
ACRIN
6666
BI-­‐RADS
5.0
2013
Ultrasound
:
Subtypes
of
cys4c
masses
of
the
breast.

7. Classification de Y‐W CHANG 2007
Chang YW, Kwon KH, Goo DE, Choi DL, Lee HK, Yang SB.
Sonographic differentiation of benign and malignant cystic
lesions of the breast. J Ultrasound Med 2007;26:47-53
Type
I
:
SIMPLE
cysts
,
anechoic
masses
with
an
impercep/ble,
circumscribed
border
and
acous/c
enhancement.
Type
II
:
clustered
anechoic
cysts
with
no
discrete
solid
components
Type
III
:
cysts
within
septa
of
less
than
0.5
mm
in
thickness.
Type
IV
:
COMPLICATED
cysts,
homogeneous
low-­‐level
echoes
that
otherwise
meet
the
criteria
of
simple
cysts,
including
cys/c
lesions
containing
fluid-­‐debris
levels
or
floa/ng
echogenic
debris.
Subtypes
of
cys4c
masses
of
the
breast.
Type
V
:
COMPLEX
solid
and
cys4c
masses
with
a
thick
wall/septa
greater
than
0.5
mm
in
thickness
or
nodules
with
at
least
a
50%
cys4c
component
Type
VI
:
COMPLEX
solid
and
cys4c
masses
:
solid
masses
with
eccentric
cys/c
foci

8. Classification de Y‐W CHANG 2007
Typical
SIMPLE
cyst
Bi-­‐Rads
2
simple cysts
clustered anechoic cysts with no discrete solid
components
cysts within septa of less than 0.5 mm in
thickness.
COMPLICATED
cyst
Bi-­‐Rads
3
Type IV : complicated cysts, homogeneous low-level
echoes that otherwise meet the criteria of simple cysts
COMPLEX
solid
and
cys4c
mass
Type V : cystic masses with a thick wall/septa greater than
0.5 mm in thickness or nodules
Subtypes
of
cys4c
masses
of
the
breast.
Chang YW, Kwon KH, Goo DE, Choi DL, Lee HK, Yang SB.
Sonographic differentiation of benign and malignant cystic
lesions of the breast. J Ultrasound Med 2007;26:47-53
«
Atypical
cyst
»

9. Category
Descrip4on
BIRADS
PPV
SIMPLE
cyst
Impercep4ble
wall
Anechoic
content
Posterior
enhancement
2
0
COMPLICATED
cyst
Thin
wall
Echogenic
content
Fluid/fluid
level
Posterior
enhancement
3
<
2%
COMPLEX
cys4c
and
solid
mass
Thick
wall
>
0.5
mm
Thick
internal
septa
>
0.5
mm
Intra-­‐cys4c
mass
(cys4c
component
>
50%
Doppler)
Solid
cys4c
mass
>
50%
4
2–95
BI-RADS®
classification of cystic lesions.
W.A.
Berg,
A.G.
Sech;n,
H.
Marques,
Z.
Zhang
Cys;c
breast
masses
and
the
ACRIN
6666
experience
Radiol
Clin
North
Am,
48
(5)
(2010),
pp.
931–987

10. Typical simple Cyst
(Type I, II, et III )
Bi-Rads 2 : no follow up , no samples.
Aspiration if painfull
Mammography
:
mass
with
circumscribed
border
Ultra-­‐sound
:
anechoic
masses
with
an
impercep/ble,
circumscribed
border
and
acous/c
enhancement.
Cyst
type
III
:
cyst
with
thin
septa
(<
0.5mm)
Cyst
type
II
:
clustered
anechoic
cysts

11. Complicated
cyst,
type
IV
:
well-­‐defined
oval
masses
with
homogeneous
internal
echoes
Regarded
as
probably
benign
with
a
very
low
risk
of
malignancy
<2%
(ACR3)
Appearance
of
solid
mass
:12%
with
malignancy
rate
0,42%
Close
monitoring
4-­‐6
months
or
ultrasound-­‐guided
FNA
(
or
CNB
)
in
cases
of
family
risk
1
2
Complicated cysts type IV
Bi-Rads 3
homogeneous
low-­‐level
echoes
cys/c
lesions
No
Solid
Parietal
mass
containing
• fluid-­‐debris
• levels
floa/ng
• echogenic
debris

12. 29
year-­‐old
2
weeks
post
partum
:
Abces

13. Complex cyst mass Type V
Bi Rads 4
Grouping
of
microcyst
:
fibrocys;c
mastopathy
associated
with
apocrine
metaplasia.
FNAB
confirm
the
diagnosis
Vacuum
biopsy
+/-­‐
Cyst
with
a
thick
wall
or
internal
septum
>
0.5
mm

14. Galactocele
FNAB
Revela/on
several
years
aTer
pregnancy
Appears
as
a
complex
mass
with
several
fluid/fluid
levels
or
thick
wall
>
0,5
mm
Complex cyst mass Type V
Bi Rads 4

15. Mammography:
mass
with
circumscribed
border
with
partly
visible
segments
cleared
by
surrounding
/ssue.
Ultrasound:
cys/c
masse
with
thick
nodules
with
at
least
a
50%
cys/c
component
with
flow
Doppler
signal
Core
needle
biopsy
histologie
:
papilloma
with
atypical
ductal
hyperplasia,
removed
by
surgical
biopsy
Complex cyst and mass Type V
Bi Rads 4

16. complex mass ans cyst de Type VI
Bi-Rads 4
fibroadenoma
Phyllod
tumor
Inv
Ductal
Carcinoma
Pregnancy
mass
fibro-­‐cys/c

17. 28-year-old
Breastfeeding
Breast mass + fever

18. Histology
:
macrobiopsy
and
surgery
:
Papillar
lesion
with
CIC
Typical
disappearance
of
propaga;on
of
sharewave
Elastography
:
BI-­‐RADS
5.0
2013
118
complex
(
87,3%
Bénign
12,7%
Malignant
Variability
inter-­‐observer
Ultrasound
mode
B
vs.Elastosonography
Korean
J
Radiol.
2013
Jul-­‐Aug;
14(4):
559–567.
33,6%
Bi-­‐Rads
4
en
Bi-­‐Rads
3

19. T1 injection
T1 inj Substraction
T2
STIR
Fat
Sat
KYSTE
pre injection
T1

21. MFK
ACR
2
Cysts in T2 ++
T1 and T2
After injection
• Punc;form
enhancement
• Size
:
<
5
mm
• RSM
(before
injec;on
+++)
• Unique
or
mul;ple
• Smooth
borders

22. BI-­‐RADS
5.0
2013
T2-­‐
weighted
signal
intensity
on
non-­‐contrast
images
Bénign
1. Cys;c
and
microcys;c
comp.
2. Fat
:
Lymph
nodes
(
Normal
or
Abnormal),
Fat
necrosis,
Hamartoma,
Postopera/ve
seroma/hematoma
with
fat.
3. Spécific
lesion
:
Fibroadenoma,
intrammary
lymph
node,
phyllodes
tumor
Malignant
1. Tumor
necrosis
2. Mucinous
subtype
cancer

23. Inflammatory
cyst
Eclips
sign
T2
Fat
Sat
Inj
+
Sub

24. RIM
Enhancement
54
ans
BRCA1
CCInv
SBR2
+
CIC
high
grade
with
necrosis
Triple
nega/ve
cancer

25. Right
:
Breast
cancer
Surgical
biopsy
led
breast
:
benign
T1
T2
STIR
Fat
necrosis

26. Cysts
galactophorics
T2
STIR
T1

27. The
malignant
cys4c
lesions
1. Bud
developed
at
the
expense
of
the
epithelium
2. Solid
tumor
totally
or
par4ally
necroses
0,2
to
0,3%
of
cancers
23%
à
31%
of
cancers
in
complex
cysts
[Berg
Radiology
2003]
Clinical
mass
well
limited
mobile
Mammography:
round
mass
with
festooned
or
lobulated
borders
Ultrasound
:
type
IV
Type
V
and
VI

28. 1
/
Sampling
for
type
IV
COMPLICATED
cysts
?
Breast
cancers
with
a
misleading
cys4c
form
1. Carcinoma
with
necrosis
(High
grade
and
Triples
nega4ves)
2. Medullar
Cancers
3. Mucinous
carcinomas
• posterior enhancement
• misleading aspect of some lesions (round, regular,
pseudocystic image Infra centimetrique
BI-Rads 3

29. Cyst
collapse
during
the
biopsy
Follow up or sampling ? FNA or CNB ?

30. CNB
Medullar carcinoma Size 12 mm
RH- HER2 -
Risk women : a radiological lesion BIRADS 3 establish an
indication of biopsy CNB due to :
– The high incidence of invasive cancers
– The natural history (evolution)
– The sometimes misleading aspect of some lesions (round, regular,
pseudocystic image) Lakhani [JNCO 1998, Tilanust -Linthors
2002]

31. • Thick wall cystic mass > 3 mm
• septa greater than 0.5 mm in thickness
• Microlobulated
• mass echoes intracyst
• No posterior enhancement
• Colour Doppler imaging positive
Type V ou VI : «complex solid and cystic mass » BIRADS 4
Core Needle biopsy
Clip
Definitve diagnosis: surgery
1. Atypical papilloma +/- carcinoma
2. Papillary carcinoma
3. Metaplasic carcinoma
4. malignant phyllodes tumors
> = 2 signs

32. Clinical
:
Palpable
mass
with
rapid
development
and
breast
deforma/on
Breast
ultra-­‐sound
:
complex
solid
and
cys/c
mass;
Core
needle
biopsy
and
surgery
:
Papillary
carcinoma
Cyst or complex mass de Type V
Bi-Rads 4

33. real
bud
intracys4c
?
No
Yes

34. 53
years
,
peri-­‐areolar
nodule
rapid
and
recent
appari/on
without
nipple
discharge
CNB
:
Papilloma
with
epithelial
hyperplasia
with
atypia
Surgery
:
intra
cys4c
carcinoma

36. • papillary
lesion
(
8%
-­‐
14%
papilloma
are
peripheral
)
• phyllodes
tumor
• atypical
ductal
hyperplasia
• in
situ
nodular
neoplasia
Risk of underestimation
the rate of malignancy found on ablated tissue ,
30% -38% requires surgical ablation
• Radiologic/histopathologic concordance

37. Interven4onal
diagnosis
strategy
Typical cyst: type I, II and III : BIRADS 2
• no follow up or not requiring intervention if patient is not
symptomatic
• symptoms such as pain or palpation owing to a very large
cyst, aspiration can be performed (analysis)
1/ Type IV : Complicated cyst
1. BIRADS 3 : short Follow up 6 month recommended ? FNAB ?
VPP 2 to 3% + risk (Patient history) : CNB
2/
Type
V
ou
VI
:
Core
Needle
Biopsy
• cys4c
mass
or
complex
mass
• BIRADS
4
CNB
or
VAB
for
small
lesion
(<
10
mm)
with
clip
• CNB
histology
:
not
enough
and
need
surgical
diagnosis
The difficulty of samples is directly related to the presence of a
fluid component (collapse during the biopsy)

38. RCC
RMLO
LMLO

40. récidiveFat necrosis
6 mm

41. Conclusion
Extremely frequent pathology sometimes with anxiety reaction.Cancer?
Ø 35 ans, Easy ultrasound diagnosis, benign
Breast Cysts
Benign or malignant
CYSTS CLASSIFICATION :
SIMPLE (BIRADS 2) COMPLICATED (BI-RADS 3) COMPLEX (BI-RADS 4)
• Ultrasound +++ (Harmonic, compound mode)
• Doppler +/-
• Elastography (specificity, non operator dependant )
• The breast RMI should not be used for the classification
• Complex masses are classified as ACR4,rate of malignancy [23 -31%]
• Histological diagnosis : CNB +/- clip ( < 1cm)
• histological verification and Radiologic/pathologic correlation is essential
Atypical cysts : 5 %

42. Breast cysts
Benign or malignant
Jean Yves Seror Centre Duroc Paris
Thank you for your attention