I just had a mammo, and had to go back for another
one and an ultrasound, they found a 1/2 inch cyst
with a smaller one next to it. My Gyno is leaving
it up to me to see a surgeon, What are your thoughts
on this?"
"I am 42 white female, I also have cysts on
my ovaries, fibroid on my uterus and just had the
Leep procedure done to get rid of bad cells on my
cervix. My periods are regular, but I do clot a lot
and bleed heavily."
Cathy
My thoughts are that you should go ahead and have
the cyst aspirated. I hope the following comments
will shed light on that simple statement.
Mammograms do not detect breast cysts. They just
show dense masses. If the radiologist suspects the
mass may have fluid in it, then an ultrasound is performed.
If there is fluid in the mass, a needle aspiration
of the cyst may be suggested. The rule-of-thumb is
that any breast mass needs to be evaluated as a possible
malignancy. If the mass is known to be solid, it is
surgically excised and sent to pathologic analysis
to see if it is a cancer. If it is a cyst, the fluid
can be drawn off and, if not bloody, it is a benign
cyst and continued observation is the course of action.
Mammograms may also look for calcifications which
can be a sign of a benign or malignant microscopic
mass that would need to be evaluated. Ultrasound can
also pick up micro calcifications in the breast and
is actually better at identifying calcifications in
invasive and in-situ breast cancer than it is in identifying
them in benign fibrocystic conditions (1).
The basic principle is that any discrete, solid breast
mass needs to be biopsied and any suspicious mass
effect on mammogram or ultrasound needs to be confirmed
as benign. In the case of a cyst, this means aspiration
of the cystic fluid. In the case of a suspicious finding
on imaging that does not have fluid in it, a core
needle aspiration biopsy (withdrawing tissue cells
into the needle and syringe rather than fluid) is
used to confirm benign changes.
How common are cysts in the breast?
Breast cysts may occur in up to 20-50% of reproductive
age women at sometime in their life. Most cysts are
very small but large cysts, macrocysts occur in up
to 7% of women (2). The peak incidence is in premenopausal
women aged 40-50. Less than 5% of cysts are in women
over 60 (3).
The glands and ducts of the breasts secrete fluid
all of the time even though they are not lactating.
The amount is so small it is not noticeable on a daily
basis but if a duct plugs up with normally sloughed
skin cells, the fluid builds up and a cyst is formed.
Cysts may be single or multiple. They are not seen
as cysts on mammography, just as a dense mass or masses.
If the radiologist suspects the mass is a cyst, an
ultrasound is performed to see if there is fluid inside
the mass. If there is, this is called a breast cyst.
The next step is to determine if the breast cyst
has more benign characteristics or could it possibly
be malignant. Benign cysts are round or oval, well-circumscribed
and usually greater than 1.4 cm in size; malignant
characteristics include irregular shape, micronodular
groups of fluid collection and having sharp edges
(4).
Are cysts in the breast the same as fibrocystic
breasts?
No. Fibrocystic changes are mostly thickened areas
of the breast glands and supporting fibrous tissue.
The breast normally is composed of mostly fatty tissue.
The glands and ducts are only a small part of the
breast unless they undergo fibrocystic change or are
stimulated by pregnancy. Fibrocystic change is much
more a fibrous than cystic but some cysts can occur.
Cysts can occur on their own or in a setting of fibrocystic
change and when they do, they present more as a discrete
mass you can get your fingers around. Fibrocystic
change alone is a diffuse, rubbery thickening without
any areas containing much fluid.
How are the breast cysts treated - what does
a surgeon do?
If there is a cystic, fluid filled area seen on ultrasound
of the breast and the characteristics are benign,
the usual treatment is to put a needle in the cyst
and draw off (aspirate) the fluid. If the fluid is
clear or yellow color but with no evidence of blood
in it, the fluid is just discarded since this always
means the cyst is non cancerous (5). The woman just
then waits to see if the cyst recurs. If it does not,
no other treatment is needed. If it does recur, an
excision of the cyst or a 2nd aspiration may be performed.
If on ultrasound the cyst appears to have any characteristics
of malignancy, or if on aspiration of a benign cyst
bloody fluid is found, then the cyst is surgically
excised just as if it were a solid lesion.
Will cysts in the breast keep coming back?
They may. In women who have breast cyst aspiration,
about 40% will have recurrences with two to five recurrences
in 36 per cent and more than five recurrences in 4
per cent (6). It seems that the younger the age at
which a woman has breast cysts, the more likely it
is she will have a recurrence.
What causes cysts in the breast?
No one knows, other than the ducts get plugged up.
It is probably not due to hormones. Birth control
pills do not cause breast cysts and actually the newer
low dose pills seem to lower the incidence of fibrocystic
breast disease (7). After menopause, hormone replacement
does not cause cyst development (8). The different
progestins can increase breast density more so than
the estrogen component but neither seem to produce
cysts.
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