Non-Simple Breast Cysts - SD

Introduction to Non-Simple Breast Cysts

Hi, this is Cindy Rapp and we're gonna talk about non simple breast cysts and how to deal with those in sonography.

Breast cysts occur far too common for us to biopsy all of them, aspirate them, or even follow them up of all of our complex cysts. We need a more rational approach on how to deal with these non simple breast cyst.

This is just one image on a patient that where everywhere pretty much that we scanned, we saw these multiple different types of complex breast cyst. As you can see, you'd have about a hundred cyst in each breast if you had to evaluate these.

We're gonna go across or go through a approach on how to evaluate these non simple breast cysts.

Traditional Criteria for Simple Cysts

We've all been taught since we were early in ultrasound that to call a cyst normal or simple cyst, that we had to have it be anti coic, nice through transmission, good posterior borders. And if it did not have all that, it was a complex cyst. And in our mind, all of these complex cyst are something that are worrisome.

Modern Imaging Challenges

With our new equipment, we're seeing much more information on the cyst. We kind of need to retrain our brain in how to deal with these.

Sometimes we'll see cysts that look like this. We have one that appears to be almost simple and sitting right next to it, we have one that looks like it's solid. They both have nice through transmission, we can see nice edge shadows coming off of them.

I know one thing that we wanna do as a sonographer is just take our gain and turn it down and make it look like it's nice in a simple cyst. But really we don't wanna be making our fat black. We wanna make sure that when we're imaging breast ultrasound, our fat stays at medium gray. We really don't wanna be turning our gain down.

Types of Complex Cysts

Sometimes we'll see cysts that look like this. The one on the left looks like it's half solid and half cystic. These we refer to as an acorn cyst.

Sometimes you'll have ones that look like they are completely solid. These are referred to as foam cyst. They can also be called gel cyst or inspissated cysts.

Cholesterol Crystals in Cysts

At times you may see low level echoes inside of cysts that actually will move if you do something that increases the intensity of the beam, such as turning on color or powered doppler or turning up your output power, you can actually get these echoes to start moving in there. And these are just cholesterol crystals that we're dealing with.

If you look at this loop I have playing here, this is putting on power doppler. You can see that we get those echos to move and it kind of looks like the 4th of July, but this is some color streaking that we can get. It's increased the intensity of the beam and cause those little echos to move in there. And once again, these are just considered a birads two and really do not need to be aspirated.

Using Color Doppler for Evaluation

If you have one of these cysts that look like it's something like a solid lesion, one thing that you can do is turn on color doppler. Just because you do not see flow within the lesion does not mean it is a cyst. However, if we do see flow, we know we're not dealing with a cyst that this truly is a solid lesion.

One other thing that I always do, anytime I turn color doppler on, I always take a picture to prove I turn color doppler on even if I don't see flow. Document that you have used color doppler on some of these non simple breast cyst just to prove to your radiologist that you did try color doppler.

Aspiration Techniques for Foam Cysts

Those foam cysts can be very thick and if you try to aspirate them, a lot of times you won't be able to get anything out of it. But if the needle is in the cyst and you're trying to aspirate it all is not lost. One thing that can be done, if it is one of these foam cyst, you can actually take the needle tip and rock it to the posterior wall and then up to the anterior wall.

If you're dealing with a true solid lesion when the needle tip is in the middle, and if you try to rotate it anterior and posteriorly, it will stay pretty much in the center of the lesion. If you are able to rock the needle tip, most likely you're dealing with one of these foam cyst and not a solid lesion.

Interpretive Difficulties and Causes of Echoes

Looking at interpretive difficulties, these aren't artifactual echoes that we're seeing. Actually what they represent is pro tenacious debris, cholesterol crystals, floating foamy, macrofasia, floating papillary, APR and metaplasia.

If you aspirate this and send it into a pathologist, it's just gonna come back as a broad spectrum of fibrocystic change.

Looking at the percent of complexes that we're seeing is increasing. One reason is we have higher frequency transducers, broader bandwidth, higher dynamic range. And what we need to do is figure out what's real echoes and real structures in there versus what is an artifact.

Different things that can produce echoes within the cyst. Protein, globs or cholesterol crystals, fat globs, white blood cell rub, blood cells, epithelial cells, floating macrophages, papillary apron, metaplasia.

We've got the pap cells, papillo and carcinomas are the solid lesions that we can also see inside of some of these cysts.

Eliminating Artifactual Echoes

The first thing we wanna do on these cysts is try and get rid of artifactual echoes. Get rid of reverberation clutter, ring down volume averaging and speckle. And one way we can do this is by using harmonics and realtime compound imaging. These are systematic approaches we can go through to try and help eliminate artifacts.

Here's an example of a cyst that's filled in with a lot of echoes on the left hand side turning on harmonics. You can see that we clean that cyst out much more, that we're more comfortable that this truly is a cyst and that we're not dealing with a solid lesion.

Looking at the lesion here on the left, this is without compound imaging. When we turn on compound imaging to the image on the right, we clear up a lot of the clutter artifact, the reading down reverberation, and we see a much more simple cyst on the right hand side image by using realtime compounding.

Real Echoes in Harmonic Imaging

If the echoes inside of the cyst are real, one thing that we have found in going into harmonic image, we actually see an increase in the echoes using harmonics. If you have real information instead of eliminating it, it actually will enhance it. We see echoes much nicer on the right hand image that has harmonics turned on.

Fibrocystic Changes

When we look at fibrocystic change, we have a mixture of cystic fibrosis and more of a proliferative change. And depending upon which way we see the fibrocystic change go, if it goes this route where we get more cystic degeneration, it's pretty easy to diagnose that sonographic when we run into problems is when we go more through the proliferative change or the fibrotic change, that lesions can look very worrisome sono graphically.

Here's just showing you an example. This first image is a normal TDLU terminal ductal lobular unit. This is the extra terminal duct that we see coming off and this is when the TDLU goes into more of a cystic degeneration, more of a cystic degeneration. You can see the small microcyst here is a cyst in large. You can see these are actual individual cysts that we see. I think we would feel more comfortable in just following up something like this.

Whereas you can see when we go through more of the fibrosis, you can see how these are very worrisome looking and I think all of us would at least recommend a biopsy when we see more of that fibrotic change versus more of the cystic change of the FCC.

Clusters of Dilated TDUs and Septations

Breast cysts that we're not as worried about is when we do see a cluster of cystic lead dilated t dus. Thin septations like this we feel much more comfortable in following. But one thing we always wanna do is turn on color doppler and make sure we do not see any flow present in there.

We do get more concerned when we see thick septations such as this. This is a lesion that we would recommend biopsy on anytime we see a fluid debris level. One thing we wanna do just the same as we would do with a gallbladder is to cube the patient. And you can see this fluid debris level will shift a lot of times. These we will aspirate to make sure that we're not dealing with pus or inflammation within that.

These fluid debris levels typically we will aspirate.

Evaluating Protrusions in Complex Cysts

Looking at this complex cyst, what we wanna do is look to see if there is any protrusion beyond the cyst wall. We sort of draw an imaginary line around it where the portion looks like it's solid. This is actually a fat fluid level. And if you draw an imaginary line around this area where we see half solid and half cystic, you can see there's an area that extends out beyond our imaginary line. Also, we've got an area of some micro loation extending on the anterior surface here. This is an area that would be more suspicious of. This actually turned out to be an intra cystic papillary carcinoma versus just a fat fluid level that we're dealing with on the image on the left.

In looking at these images here, the one that we see on the left labeled acorn cyst is dealing with a fat fluid level. What we wanna do is take a look once again where the solid portion of it is and see if there's anything extending out beyond the edge of the wall. There's nothing extending beyond the wall. This is more reassuring that this is just fat fluid. This is a birads two.

Looking at this cyst here where we see the solid portion, you notice that there is an actually a little nose that extends out. This turned out to be an intra cystic papilloma. And then looking at this area here, we can see some micro loation along here. The cyst should come and stop right about here. And we can see an area extending beyond. This is an intra cystic papillary carcinoma.

In evaluating those solid and cystic type of patterns, that's how you wanna look at those.

Inflamed Breast Cysts

Sometimes we can also see breast cyst. A normal breast cyst will have a thin echogenic wall. You can see the image on the right hand side. This is a normal simple cyst. The wall is nice and thin and echogenic.

On the left hand side, what we can see is an inflamed breast cyst With inflammation, the wall becomes thick and iso coic. Instead of being nice and thin and echogenic, it's thick. And iso coic, we can see a fluid debris level. This is an area with some pus in here and also there is hyperemia within this cyst wall. And we turn on color doppler. We can see that it is an inflamed cyst and this is one that needs to be treated.

Sebaceous Cysts

Other cysts that we can evaluate with ultrasound are sebaceous cyst. These are all given a birads two classification, meaning it's a benign lesion.

These cysts can be completely within the skin. We may see them partially within the skin or they may be located deep to the skin. This is looking at a lesion that is very superficial, so anything superficial, we wanna make sure we use a big glop of gel to evaluate. But all of these are cyst arising from the skin. You can see their skin completely surrounding each one of these sebaceous cyst.

Looking at these next ones, these are ones that appear to be halfway in the skin and halfway into the subcutaneous fat. But one thing you'll notice that we look for is the claw sign. It is where to the skin is grabbing onto the edge of it. So right across here is a claw sign grabbing onto that we know the origin is from the skin. And here's another example of a claw sign on each of these. Once again, we are more assured that we are dealing actually with sebaceous cyst.

The third type that we will see is when the main portion of the lesion is deep to the skin. And what the key to making this diagnosis is looking for the gland or the neck as it passes through the skin surface. So each of these appear to be deep to the skin. The skin comes right across here, and this is the actual hair follicle from this infected cyst to rise. So right through here. And each one of these we can see this otherwise would appear almost as a fibroadenoma, but this is just an inflamed sebaceous cyst because we can see the hair follicle from which it arises.

If you notice that, just showing you pathology specimen notice hair follicles do not go straight up to the skin, but they actually come in at more of an angle.

Conclusion

Breast ultrasound is very helpful in evaluating all of these different types of complex cyst. Thank you for your attention.