Breast cysts Benign or malignant

Jean Yves Seror

Centre duroc

Paris

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

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

 • 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

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.  

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  

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    

Bi-­‐Rads  4  :  malignité  20%  -­‐36%  

Type V : cystic masses with a thick wall/septa greater than

0.5 mm in thickness or nodules

Type VI : complex solid and cystic masses

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  »

 

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  

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  

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    

29  year-­‐old  2  weeks  post  partum  :    Abces  

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  

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

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

complex mass ans cyst de Type VI Bi-Rads 4

fibroadenoma  

Phyllod  tumor   Inv  Ductal  Carcinoma    Pregnancy  

mass  fibro-­‐cys/c  

28-year-old Breastfeeding Breast mass + fever

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  

T1 injection T1 inj Substraction

T2  STIR  Fat  Sat  

KYSTE  

pre injection

T1

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    

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    

Inflammatory  cyst  

Eclips  sign  

T2  Fat  Sat   Inj  +  Sub  

RIM  Enhancement  

54  ans  BRCA1    CCInv  SBR2    +  CIC  high  grade  with  necrosis    

Triple  nega/ve  cancer  

Right  :  Breast  cancer    Surgical  biopsy  led  breast  :  benign  

T1   T2  STIR  

Fat  necrosis  

Cysts    galactophorics  

T2  STIR  T1  

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    

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

Cyst  collapse  during  the  biopsy

Follow up or sampling ? FNA or CNB ?

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]

•  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

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

real  bud  intracys4c  ?  

No  

Yes  

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

•  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

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)

RCC  

RMLO   LMLO  

récidive Fat necrosis

6 mm

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 %

Breast cysts Benign or malignant

Jean Yves Seror Centre Duroc Paris

Thank you for your attention