\OL.

115,

No.

DIAGNOSIS

AND
By

MANAGEMENT

HEBERT,

GUY

M.D.,

and

Downloaded from www.ajronline.org by 114.79.28.152 on 10/31/15 from IP address 114.79.28.152. Copyright ARRS. For personal use only; all rights reserved

MONTREAL,

YSTIC

disease

lesion
every
io

of the
women

dent

cysts

is

the

most

breast,
develops

before

her

as

OF

DENISE

common
evi-

These

difficult

palpable

had

been

cidence
the

could
general

presence

Fic.

disease

i.

be

in the
as high

population.
of cystic

(A)

Large,

and

as

times

mass,

of the

with

regular
the

From

the

Department

in-

that

of

of Radiology,

Notre-I)ame

wall

may

the

Hospital,

(B)
cyst

much

After

is thin

Montreal,

8oi

When

one

must

lesion.
m astectom

recommended

in

risk

ofcancer,

too

radical

A practice

cedure.

contour.
of

mass,

the great

the

breast

to interpret.

is a benign
Simple

the

Furthermore,

lesions

ovoid

past,

M.D.

CANADA

cysts
are often
the cause
of pain,
especially
in the premenstrual
period.
It seems
that
cancer
is more
frequent
in patients
having

cystic

CYSTS*

prevent
early
discovery
of a small
cancer.
In fact,
the dense
and fibrocystic
breast
is
both clinically
and roentgenologically
very

in

menopause.

OUIMET-OLIVA,

QUEBEC,

about
grossly

BREAST

aspiration,
and

Quebec,

regular.
Canada.

has

sure

h as

occasion

past

because

but

this

is evidently

and

been

that

the

that

air has

a woman

make

it

ally

of

unjustified
prois more
widespread

introduced.

Note

that

Downloaded from www.ajronline.org by 114.79.28.152 on 10/31/15 from IP address 114.79.28.152. Copyright ARRS. For personal use only; all rights reserved

11G.

2.

(A)

Moderate

is tile

excision

make

tileir

of

admission

under

general

the patient
numerous
does
can

and

the

to

somewhat

cysts

on

are

Cst

easier

to note

refill

after

11G.

4. (A)

that

basis

aspiration.

A smaller

tumor,
contours

cysts

is

be

If, after
troduced

or even

as often
as
It is impordo

Aspiration

not

usually

of

Aspiration

and

injection

ofair

the

1972

demon-

cysts
also
provides
fluid
for cytology
and
culture,
although
this
is regarded
by most
as unnecessary.
Even
after
complete
evac-

it

It

anesthesia.

an outpatient

these

and

(B)
cyst.

AGSr,

uation,
a small
cancer
in the wall
even
though
this is a rare occurrence,

leaves

sometimes
puncture

at the office.
It can be repeated
necessar
and
leaves
no scar.
tant

it

Ouimet-Oliva

in the dense breast.

that it is a simple

they

to perform

general

Denise

however,
inand surgery
and

that

mutilating.

necessitate

lost
strate

whenever

This,
hospital

scars

simple,

be done

mass

anesthesia,
with

more
not

size

appearance.

volves

much

H#{233}bert and

Guy

802

of a cyst,
could

missed.

aspiration
into the

are obtained
in
benign
character
any

although

consists

of

An

still

injecting

is in-

at least
2 projections,
the
of the lesion
can be proved

doubt.

beyond

cated,

the anterior
border
of which
is not well
appear
very regular
and thin, indicating

ofthe
fluid,
a gas
cavity
and mammograms

even

very

more

simple,

a drop

defined.
(B) After
a simple
cyst.

of

filling

sophistitechnique

opaque

with

me-

air

the

Downloaded from www.ajronline.org by 114.79.28.152 on 10/31/15 from IP address 114.79.28.152. Copyright ARRS. For personal use only; all rights reserved

Downloaded from www.ajronline.org by 114.79.28.152 on 10/31/15 from IP address 114.79.28.152. Copyright ARRS. For personal use only; all rights reserved

FIG.
in

(A-D)

different

neoplasm.

fairly
projections

well

defined
shows

and

benign

a tumor

looking
projecting

mass

has

been

from

the

wall

aspirated
into

and
the

lumen,

filled

with
indicating

air.

Exposure
malignant

Downloaded from www.ajronline.org by 114.79.28.152 on 10/31/15 from IP address 114.79.28.152. Copyright ARRS. For personal use only; all rights reserved

VOL.

FIG.

115,

1)iagnosis

No.

6. (A and

B) After

incomplete
proved

that

Skin

retraction

and

well

as axillary

lymphadenopathy

edema

Management

and

aspiration,
it was
(orange

a small

fluid
skin)

are

left

air-fluid

in the
as

lack-

ing.
ROENTGENOLOGIC

of

FINDINGS

On the plain
mammogram,
cysts
appear
as well delineated,
round
or ovoid
masses.
Often
one can see a thin
radiolucent
line
around
the cyst.
Fibroadenomas
are also
usually
well delineated,
but they
are often
lobulated
and
commonly
contain
large,
dense
calcifications.
An
important
diagnostic
point
is the
radiotactile
ratio;
i.e., the comparison
of
the size of the palpated
mass
to the size of
the lesion
on the mammogram.
If the mass
is significantly
larger
by palpation
than on
the mammogram
it is certainly
suspicious

cyst

ofbeing

Breast

level

Cysts

is noted.

rather

malignant;

that
nign

surrounds
lesions

size

cli nicallv
in benign

nally,

classical

However,

a thick

than

signs

8o

different

projections

wall.

this

is due

to tile

edema

the
malignant
tumor.
usuall
of about
the

are

and
of

roentgenologically.
lesions
such
as
malignancy

are

Besame

cysts

Fitile

lacking;

e.g., thickening
and
retraction
of the skin
or nipple,
microcalcifications
and increased
vasculari
ty.
Roentgenograms
of air-filled
cysts
provide
a definite
diagnosis
(Fig.
i, zi
and B).
TECHNIQUE

Under
aseptic
conditions
and local anesthesia,
a 21 gauge
needle
is introduced
into
the mass which
is held between
the thumb
and forefinger
of the other
hand.
lithe
mass
is really
a cyst, the fluid should
come freely

Gu

8o6

H#{233}bert
and

Denise

Ouimet-Oliva

AUGUST,

1972

Downloaded from www.ajronline.org by 114.79.28.152 on 10/31/15 from IP address 114.79.28.152. Copyright ARRS. For personal use only; all rights reserved

#{149}
5L;4.

(A)

7.

11G.

A small

that

tumor

as

injection

not
of

palpable

air

was

demonstrated

mass

with
open

around

it. Ifso,
biops-

to
tile

or

see

if the

needle

witil

the
c\st
has
without
a drop

or

is introduced
1

be

into

B). The

and

an
be

a little

less

drawn
because
expansion
of

been

the
the

introduced

into

the

this

could

interstitial
prevent

been
aspirated,
air,
of opaque
medium,

it (Fig.

amount
than

2,

B; and

A and

3,

ofair
injected
should
that
of the fluid
with-

heat
of the body
gas.
If too much

there

might

tissue
adequate

be

of the

causes
air has

diffusion
breast

visualization.

plain

was

a simple

and

additional

(B)

mammogram.

are

obtained,

another
Once

one

in

if

drawn.

The

department
year,
unless

the

patient
i

she

superior
roentgenoquality
and

for

have

necessary,

air

is asked

month

later

discovers

in pro-

the
the

checked

roentgenograms

tamed

and

Aspiration

cyst.

Roentgenograms

performed.

After

the

it

file
view
and
inferior
projection.
grams
have
been

moves

then
is solid
and
should
probably

lesion

excision

on

that

into
tile
syringe
especially
if it is under
pressure.
If no fluid is aspirated,
the position
of the needle
should
be checked
by moving
the

seen

been

can

be

to return

and
new

then
masses

obwithto the

twice

in her

breasts.
RESULTS

The

air-filled
cyst
appears
as a radiolucent
mass
that has a thin and regular
wall,
both
sides
of which
are well defined
and
smooth
(Fig. 4, zI and B). A thick or irregular wall should
be regarded
as suspicious.
Very

rarely

a tumor

grows

along

the

wall

of

\OL.

Diagnosis

No.

115,

and

Downloaded from www.ajronline.org by 114.79.28.152 on 10/31/15 from IP address 114.79.28.152. Copyright ARRS. For personal use only; all rights reserved

the cyst
(Fig.
5, .1-D).
In these
open
biopsy
is obviously
indicated.
The
cyst should
be completely
ifpossible

because

otherwise

Management

cases

an

emptied

a small

amount

fluid might
simulate
a thick wall
1 and B). When
complete
aspiranot been
feasible,
different
views
positions
should
be obtained
so
inner
wall can be entirely
visual-

ofresidual

(Fig.
6,
tion has
in different
that
the

sists,

mass

a biopsy

remaining.

should

roentgenograms
mass

The
late

is not

due

should
If a mass

be
per-

provided

the

be done,

show

that

to fluid

left

the

ally

straw

origin,

colored

if the

whereas

older

latter
cysts

cyst.

reaccumucyst
yield

and darker
fluid
which
may
be
often
green.
Sometimes
the fluid
somewhat
gray,
presumably
due
mation.
If the fluid
is red,
the
probably
not a simple
cyst
but
which
a cancer
or a papilloma
is

CONCLUSION

disease

of the

Cyst
method

puncture

surgery

under

thicker

is

in

been

For

some

office

time
in

and

our

we

have

performed

department

and

cyst
at

we
have
so
It is a simple
time
and money

demonstrated
7, 4l and

by

B).

com-

and
with
diag-

at

easy

and

and

a u nnecessary.

especially
with

accurate

air,

a precise

after

is of great

and

definitive

the

cyst

value

in

diag-

Guy H#{233}bert,M.D.
Department
of Radiology
Hospital
1560

Notre-Dame
East

Sherbrooke

Montreal,

Quebec,

Canada

REFERENCES

m ammogra-

J.

I. BOLTON,

A.M.A.

the

far not
had
a
complication.
procedure
which
could
be
saving
as compared
to surgical
excision.
We believe
that
radiology,
especially
mammography
of the
air-filled
cysts,
is a useful
adjunct
to proper
and definitive
diagnosis
and that
it helps
to avoid
errors,
particularly
in dysplastic
breasts
that may be deceiving
at palpation.
In these
breasts,
a small
residual
tumor
may
not
be palpable
after
aspiration,
or
other
cysts
that
were
not
palpable
are
sometimes
phy
(Fig.

is very

hospitalization

anesthesi

filled

arriving
nosis.

an

renders

Mammography,

brown
or
appears
to inflamlesion

is

which

DISCUSSION

punctures

breast

mon.
An increased
incidence
of cancer
the possible
confusion
ofcystic
masses
cancer
or vice versa demand
a precise

has

recent

a cyst
growing.

807

We have
also done
a few ultrasonic
examinations
in these
cases but we have
not
been too impressed
by the results
so far. It
helps to distinguish
between
cysts and solid
tumors,
but
either
aspiration
or excision
still has to be done subsequently.

is usu-

is of

Cysts

nosis.

residual

in a benign

aspirated
cysts
very seldom
unless
they
are malignant.
The fluid aspirated
from the

Breast

Cystic

ized and an irregularity

excluded.
After
complete
aspiration
there

no palpable

of

GROS,

3.

HAAGENSEN,

med.

nucl#{233}aire,

HERMANN,

73,

J.,

G.,

K05S0FF,

T. S. Ultrasonic
7. Australia,
I971,
D. Structural

REEVE,

7.

222-228.

52,

40-43.

JELLINS,

M.

1971,

of the Breast.
W. B.
Company,
Philadelphia,
1971.
J. B. Mammary
cancer
subsequent
to
ofcysts
in breast.
Ann.
Surg.,
1971,

aspiration

6.

Surg.,

C. D. Diseases

Saunders

5.

cyst
and
hospital
bed.
1970, JO!,
.382-384.
M. Echographie
mammaire
7. de radiol.
d#{233}lectrol. et de

Breast

C., and JACOB,

et thyroldienne.

2.

4.

P.

Arch.

BUDDEE,

visualization

F. W., and
of breast.

I, 305-308.

of
adenoid
cystic
7.
C/in. Path., 1970,
ROSEMOND,
S. P., MAIER,
W. P., and BROBYN,
T. J. Needle
aspiration
of breast
cysts.
Surg.,
Gynec.
& Obst.,
1969,
/28, 35 1-354.

LUSTED,

and
growth
patterns
carcinoma
of breast.
Am.
54, 419-425.