Cystic breast masses and the ACRIN 6666 experience

Abstract

Masses due to cystic lesions of the breast are extremely common findings on mammography, ultrasonography, and magnetic resonance imaging. Although many of these lesions can be dismissed as benign simple cysts, requiring intervention only for symptomatic relief, complex cystic and solid masses require biopsy. Perhaps, the most challenging are complicated cysts, that is, cysts with internal debris. When the debris is mobile or a fluid-debris level is seen, complicated cysts can be dismissed as benign findings. As an isolated finding, homogeneous complicated cysts can be classified as probably benign, with intervention only considered with interval development or enlargement, abscess is suspected, or if suspicious features develop. When multiple and bilateral complicated and simple cysts are present (ie, at least three, with at least one in each breast), a benign, BI-RADS 2, assessment is usually appropriate. Clustered microcysts are common benign findings in pre- and perimenopausal women, though short-interval surveillance may be appropriate for many such lesions in post-menopausal women, particularly if the lesion is new or rather small or deep (ie, diagnostic uncertainty).

Fig. 1

A 74-year-old woman was noted to have a new mass on screening mammography and no history of hormone use. (A) Spot magnification craniocaudal (CC) view shows partially circumscribed, partially obscured 7-mm mass (arrow). (B) Targeted ultrasonography shows anechoic circumscribed mass (arrow) with minimal posterior enhancement, that is, a simple cyst, corresponding to the mammographic abnormality, a benign finding. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 2

A 54-year-old woman was noted to have a new mass on screening mammography. (A) Close-up of mediolateral oblique (MLO) mammogram shows lobulated, circumscribed mass (arrow). (B, C) Targeted ultrasonography shows lobulated simple cyst corresponding to the mammographic abnormality, a benign finding. Apparent thin septation in image (C)(arrow) is due to lobulation of the cyst. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 3

A 43-year-old woman was noted to have a changing pattern of multiple bilateral partially circumscribed, partially obscured (PCPO) masses on screening (A)CCand(B) MLO mammograms, most compatible with cysts, which were confirmed on screening ultrasonography (not shown). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 4

A 43-year-old woman had a history of cysts and presented with a lump in the left breast. (A) Bilateral CC and (B) MLO mammograms show minimal scattered fibroglandular density and multiple bilateral PCPO masses consistent with the history of cysts. Ultrasonography is appropriate at least to evaluate the dominant, palpable mass (marked with a radiopaque marker). (C) Spot compression view was performed, but, in this case, it is not necessary before (D) targeted ultrasonography, which confirmed a benign simple cyst. Aspiration is typically only performed for symptomatic relief or diagnostic uncertainty. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 5

On screening mammography, a 65-year-old woman was noted to have a circumscribed oval mass containing calcifications that were punctate and amorphous and changed appearance between (A) CC and (B) MLO views (arrows). (C) True lateral view was obtained, showing the calcifications to layer in the inferior aspect of the mass (arrow), compatible with milk of calcium within a cyst. Layering calcifications were also evident on (D) ultrasonography (arrow), although not all the echogenic calcifications layer (arrowheads). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 6

A 64-year-old woman has a changing pattern of bilateral PCPO masses on (A) initial CC views and (B) CC views obtained 3 years later. One slightly larger mass (arrow) was recalled for additional evaluation on the latter examination. (C) Radial and (D) antiradial ultrasonography targeted to the recalled mass showed a complex cystic and solid mass (denoted by calipers), as well as an adjacent simple cyst. Ultrasound-guided core biopsy and excision showed benign phyllodes tumor. Multiple simple cysts were also present in both breasts. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 7

A 45-year-old woman had a history of cysts and now had bilateral tender palpable masses marked by radiopaque markers on (A) CC and (B) MLO mammograms. (C) Multiple static ultrasonographic images of the palpable lumps were interpreted as bilateral cysts. One lump was aspirated (upper inner right breast [marked by arrows in A and B]), yielding malignant cytology. (D) Repeat ultrasonography of the known malignant mass in the right breast at 2-o’clock position shows it to be indistinctly marginated and lobulated both without and (E) with spatial compounding. Any lesion documented on ultrasonography should have images recorded without calipers to facilitate margin assessment. Images of the tumor from the initial ultrasonography in part C (the bottom left image) had too narrow a dynamic range (effectively too few shades of gray); hence, the solid mass appeared anechoic. (F) Sagittal image from 3-dimensional fat-suppressed spoiled gradient echo (SPGR) MR imaging 1.5 minutes after 0.1 mmol/kg of gadolinium-based contrast injection shows an irregular enhancing mass (arrow) corresponding to the known grade III invasive ductal carcinoma. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 7

A 45-year-old woman had a history of cysts and now had bilateral tender palpable masses marked by radiopaque markers on (A) CC and (B) MLO mammograms. (C) Multiple static ultrasonographic images of the palpable lumps were interpreted as bilateral cysts. One lump was aspirated (upper inner right breast [marked by arrows in A and B]), yielding malignant cytology. (D) Repeat ultrasonography of the known malignant mass in the right breast at 2-o’clock position shows it to be indistinctly marginated and lobulated both without and (E) with spatial compounding. Any lesion documented on ultrasonography should have images recorded without calipers to facilitate margin assessment. Images of the tumor from the initial ultrasonography in part C (the bottom left image) had too narrow a dynamic range (effectively too few shades of gray); hence, the solid mass appeared anechoic. (F) Sagittal image from 3-dimensional fat-suppressed spoiled gradient echo (SPGR) MR imaging 1.5 minutes after 0.1 mmol/kg of gadolinium-based contrast injection shows an irregular enhancing mass (arrow) corresponding to the known grade III invasive ductal carcinoma. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 7

A 45-year-old woman had a history of cysts and now had bilateral tender palpable masses marked by radiopaque markers on (A) CC and (B) MLO mammograms. (C) Multiple static ultrasonographic images of the palpable lumps were interpreted as bilateral cysts. One lump was aspirated (upper inner right breast [marked by arrows in A and B]), yielding malignant cytology. (D) Repeat ultrasonography of the known malignant mass in the right breast at 2-o’clock position shows it to be indistinctly marginated and lobulated both without and (E) with spatial compounding. Any lesion documented on ultrasonography should have images recorded without calipers to facilitate margin assessment. Images of the tumor from the initial ultrasonography in part C (the bottom left image) had too narrow a dynamic range (effectively too few shades of gray); hence, the solid mass appeared anechoic. (F) Sagittal image from 3-dimensional fat-suppressed spoiled gradient echo (SPGR) MR imaging 1.5 minutes after 0.1 mmol/kg of gadolinium-based contrast injection shows an irregular enhancing mass (arrow) corresponding to the known grade III invasive ductal carcinoma. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 8

A 57-year-old woman had multiple bilateral PCPO masses on (A) CC and (B) MLO screening mammograms, compatible with cysts or other benign nodules. (C) CC and (D) MLO mammograms of the same woman, obtained 3 years later, show changing pattern of bilateral cysts as well as interval development of an indistinctly marginated dense mass at the site of a new palpable mass (marked by triangular markers). The mass is seen better on (E) spot compression CC and (F) close-up MLO views. (G) Transverse and (H) sagittal ultrasonographic images show an irregular complex cystic and solid mass with a surrounding echogenic halo, highly suggestive of malignancy. Ultrasound-guided biopsy and excision showed grade III infiltrating ductal carcinoma not otherwise specified, ER+, her2/neu−, with negative sentinel nodes. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 8

A 57-year-old woman had multiple bilateral PCPO masses on (A) CC and (B) MLO screening mammograms, compatible with cysts or other benign nodules. (C) CC and (D) MLO mammograms of the same woman, obtained 3 years later, show changing pattern of bilateral cysts as well as interval development of an indistinctly marginated dense mass at the site of a new palpable mass (marked by triangular markers). The mass is seen better on (E) spot compression CC and (F) close-up MLO views. (G) Transverse and (H) sagittal ultrasonographic images show an irregular complex cystic and solid mass with a surrounding echogenic halo, highly suggestive of malignancy. Ultrasound-guided biopsy and excision showed grade III infiltrating ductal carcinoma not otherwise specified, ER+, her2/neu−, with negative sentinel nodes. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 9

A 30-year-old woman presented for evaluation of palpable masses. The masses were shown to be cysts on (A) radial and (B) antiradial ultrasonographic images. The more superficial cyst shows reverberation artifacts paralleling the anterior wall of the cyst (arrowheads). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 10

(A) Transverse and (B) sagittal ultrasonographic images (L12-5 MHz transducer) of a 47-year-old woman with incidental cyst containing a thin (<0.5 mm) septation (arrows) on ACRIN 6666 screening ultrasonography, which was stable for 3 years. This is a benign finding. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 11

A benign cyst showing thin internal septation (arrows)on (A) radial and (B) antiradial ultrasonographic images in a 46-year-old woman. Often such cysts will be shown to communicate with each other if aspiration is attempted. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 12

A 35-year-old woman was noted to have a mass that was initially questioned as a complex cystic and solid mass on (A) transverse sonography (L15-4 MHz transducer). On (B) sagittal and (C) radial images, the mass was shown to correspond to a group of adjacent small cysts. This is a benign finding. (Courtesy of Dr Linda Hovanessian Larsen, Keck University School of Medicine, University of Southern California, Los Angeles, CA, via SuperSonic Imagine.)

Fig. 13

In the ACRIN 6666 protocol, on baseline screening a 54-year-old woman by (A) radial and (B) antiradial ultrasonography, a small cyst was incidentally identified, which communicates with a duct (arrowheads). The cyst contains a single thin septation (arrow). This is a benign finding. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 14

Radial ultrasonographic image shows incidental group of small cysts (arrow) communicating with a duct (arrowheads) in a 51-year-old woman who underwent screening ultrasonography due to a strong family history of breast cancer and dense breasts. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 15

A 39-year-old woman was followed up for cysts and complicated cysts. On (A) elastography with Hitachi equipment (or also Toshiba), cysts can have a layered and usually trilaminar appearance (arrows), appearing stiffer (blue on these devices) anteriorly and softer (red on these devices) posteriorly. Sometimes there is an apparent fourth layer (open arrow) in the region of posterior enhancement, analogous to the bright area on Siemens and Philips equipment. This is a simple cyst on (B) B-mode ultrasonography image. (Courtesy of Dr Christopher Comstock, Memorial Sloan Kettering Cancer Center, New York, NY.)

Fig. 16

A 35-year-old woman presented for evaluation of a palpable abnormality and was noted to have a cyst on (A) and (C) conventional ultrasonography (L17-5 MHz transducer, Philips Ultrasound, Bothell, WA, USA). (B) On EI (elastography imaging) setting 2, a target or bull’s-eye appearance is seen (white arrow) in which the cyst is a void with a central bright area because of the motion of cyst fluid. Also, a bright area is noted just deep to the cyst (red arrow). (D) On EI setting 1, the cyst a black void (arrow) with posterior bright area. (Courtesy of Richard G. Barr, MD, PhD, Radiology Consultants, Youngstown, OH.)

Fig. 17

A 40-year-old woman was found to have a mass on screening mammography. (A) Targeted ultrasonography showed an intraductal mass (arrow), which was hypervascular on power Doppler (not shown). (B) Elasticity image shows bull’s-eye appearance to the fluid (solid arrows) on either side of the solid, gray, stiffer, biopsy-proven papilloma (white arrow). Posterior bright areas (red arrows) are also noted deep to the cystic portions. (Courtesy of Richard G. Barr, MD, PhD, Radiology Consultants, Youngstown, OH.)

Fig. 18

Simple cyst on (A) gray-scale (L15-4 MHz transducer) and (B) shear-wave elastography. Cysts typically appear mostly black or dark blue (ie, soft) on this type of elastography. (Courtesy of Dr Philippe Henrot, Nancy, France, via SuperSonic Imagine.)

Fig. 19

This 42-year-old woman had a palpable axillary mass, incorrectly attributed to cysts on (A) transverse sonography. (B) MLO mammograms show portion of a dense mass corresponding to the palpable axillary mass (arrow). Ultrasound-guided core biopsy showed metastatic grade III invasive ductal carcinoma. (C) Sagittal subtraction image from contrast-enhanced spoiled gradient echo (SPGR) MR imaging shows bulky, enhancing, axillary adenopathy (long arrow). Tiny enhancing breast lesion (short arrow) proved benign, and the primary was never identified. The patient underwent excision of the nodes, chemotherapy, and radiation therapy to the breast and was disease free 5 years later. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 20

A 60-year-old woman was noted to have a nearly anechoic but slightly irregular mass on (A) ultrasonography. Internal vascularity was demonstrated on (B) power Doppler. Biopsy showed medullary carcinoma, a special type of invasive ductal carcinoma. (Courtesy of Dr Catherine Balu-Maestro, Centre Antoine Lacassagne, Nice, France, via SuperSonic Imagine.)

Fig. 21

A 64-year-old woman underwent (A) ultrasonography, demonstrating a nearly anechoic irregular mass with posterior enhancement. (B) On power Doppler, marked internal vascularity was demonstrated, confirming the solid nature of this spindle cell sarcoma. (Courtesy of Dr David Cosgrove, Charing Cross Hospital, London, UK, via SuperSonic Imagine.)

Fig. 22

A 41-year-old woman presented with a palpable mass. (A) Radial and (B) antiradial ultrasonographic images (L12-5 MHz) showed oval circumscribed mass (arrows) with homogeneous low-level echoes and posterior enhancement, which is typical of a complicated cyst with debris. This mass was aspirated to resolution at patient request, yielding a cloudy yellow fluid that is typical of benign cyst content and therefore it was discarded. An adjacent simple cyst was incidentally noted. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 23

A 52-year-old ACRIN 6666 participant had multiple findings on her third annual screening ultrasonography, including multiple cysts. On (A) radial and (B) antiradial ultrasonography with power Doppler, a mass seen at 2-o’clock position in the left breast was thought to be a complicated cyst and was recommended for a 6-month follow-up. On (C) radial and (D) antiradial ultrasonographic images of the right breast, at the 12-o’clock position, a few calcifications were noted (red circles), which were dismissed as fibrocystic changes adjacent to several small cysts. No calcifications were seen mammographically. At follow-up after 7 months, (E) radial ultrasonography showed that the left breast mass had enlarged (arrow), prompting ultrasound-guided biopsy. This mass proved to be a 6-mm node-negative invasive lobular carcinoma. (F) Radial ultrasonography of the 12-o’clock position in the left breast appeared unremarkable. Follow-up (G) transverse and (H) sagittal ultrasonography on the right side showed an enlarging isoechoic mass with calcifications (red ovals). This mass proved to be a 6-mm grade I IDC+DCIS and node negative. Seen only on (I) CC and not on (J) MLO mammograms, a subtle area of distortion was noted in the 12-o’clock position of the left breast (short solid arrow), which proved to be a 5-mm tubular carcinoma (grade I IDC, special type) with associated DCIS. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 23

A 52-year-old ACRIN 6666 participant had multiple findings on her third annual screening ultrasonography, including multiple cysts. On (A) radial and (B) antiradial ultrasonography with power Doppler, a mass seen at 2-o’clock position in the left breast was thought to be a complicated cyst and was recommended for a 6-month follow-up. On (C) radial and (D) antiradial ultrasonographic images of the right breast, at the 12-o’clock position, a few calcifications were noted (red circles), which were dismissed as fibrocystic changes adjacent to several small cysts. No calcifications were seen mammographically. At follow-up after 7 months, (E) radial ultrasonography showed that the left breast mass had enlarged (arrow), prompting ultrasound-guided biopsy. This mass proved to be a 6-mm node-negative invasive lobular carcinoma. (F) Radial ultrasonography of the 12-o’clock position in the left breast appeared unremarkable. Follow-up (G) transverse and (H) sagittal ultrasonography on the right side showed an enlarging isoechoic mass with calcifications (red ovals). This mass proved to be a 6-mm grade I IDC+DCIS and node negative. Seen only on (I) CC and not on (J) MLO mammograms, a subtle area of distortion was noted in the 12-o’clock position of the left breast (short solid arrow), which proved to be a 5-mm tubular carcinoma (grade I IDC, special type) with associated DCIS. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 24

A 59-year-old ACRIN 6666 participant had prior left breast conservation therapy for cancer. On the third annual screening ultrasonography, 2 masses were noted in the outer right breast on (A) oblique, (B) antiradial, and (C) radial images. The first mass was nearly isoechoic, microlobulated, and contained echogenic calcifications (arrows) and was recommended for biopsy. Just deep to this mass was an oval mass with probable fluid-debris level which was thought to be a complicated cyst (short solid arrows). The first mass was proved to be a 12-mm grade II IDC with DCIS. The deeper mass was also excised and also proved to be grade II IDC with DCIS. Sentinel node showed metastatic disease. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 25

On screening ultrasonography, a 54-year-old ACRIN 6666 participant was noted to have 2 small adjacent cysts with fluid-debris levels (arrows). These are complicated cysts with debris, benign findings, and such lesions do not require any follow-up. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 26

A 45-year-old woman noted a palpable lump. Targeted (A) radial and (B) antiradial ultrasonography show a complicated cyst containing echogenic cholesterol crystals, which were mobile on real-time evaluation. Aspiration can be performed electively for symptomatic relief, but this is a benign finding. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 27

A 68-year-old woman was noted to have a palpable mass at the nipple, marked by triangular markers on (A) spot compression CC and (B) MLO mammograms that show the palpable abnormality to correspond to a dense indistinctly marginated mass with overlying skin retraction. (C) Radial and (D) antiradial ultrasonography show intracystic mass (arrows). Additional oblique ultrasonographic images (E, F) show fluid-debris level (arrowheads) formed due to hemorrhage from the intracystic mass (arrow). A 14-gauge core biopsy showed atypical papilloma. Excision showed 8 mm of DCIS involving a papilloma, with 3-mm microinvasive colloid carcinoma. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 28

A 52-year-old woman had a palpable mass on the right breast. On standard (A) radial and (B) antiradial ultrasonographic images, the mass was cystic with a fluid-debris level (arrows). There was also a question of an intracystic mass (short solid arrow). The patient was then positioned (C) in the right-side decubitus and then (D) the left-side decubitus positions. The fluid-debris level shifted accordingly (arrows), and the intracystic mass persisted (short solid arrow). Ultrasound-guided aspiration was performed, yielding bloody fluid. Core biopsy of the residual mass showed papillary DCIS (which had bled, causing the fluid-debris level). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 29

On screening ACRIN 6666 ultrasonography, a 54-year-old woman was noted to have a circumscribed oval mass with posterior enhancement in the outer right breast on (A) supine position. Internal echoes were noted, and it was uncertain whether the echoes represented debris or an intracystic mass. (B) The patient was then positioned in left lateral decubitus (LLD) position and reimaged after 3 minutes, showing a shift in the contents, which is consistent with debris. This is a benign complicated cyst with no evidence of an intracystic mass. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 30

A 59-year-old woman with dense breasts was referred for biopsy of indeterminate calcifications in the right breast. Screening ultrasonography was performed, demonstrating 2 adjacent, mostly circumscribed, hypoechoic masses with posterior enhancement suggestive of complicated cysts (labeled 1 and 2) on (A) radial and (B) antiradial sonograms of mass 1. (C) Radial and (D) antiradial images of mass 2. Radial power Doppler images (E, F) of mass 2 show internal vascularity, which is not found with cysts. As such, biopsy was performed of both masses, showing multifocal grade III invasive ductal carcinoma. The original calcifications referred for biopsy proved to be high nuclear grade DCIS. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 31

A 52-year-old woman underwent screening ultrasonography that showed an incidental circumscribed oval mass with uniform low-level echoes on (A) gray-scale image (arrow) compatible with either complicated cyst or solid mass. (B) Elastogram (Antarres, Siemens-Acuson, Mountain View, CA, USA) shows the lesion to have a bull’s-eye appearance, being centrally white and peripherally dark (arrow), that is typical of a cyst (in this case, a complicated cyst with debris). The lesion measured the same diameter on both images (dotted lines). Stiff lesions, including many cancers, tend to appear larger on elastography. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 32

(A) On conventional gray-scale ultrasonography (L15-4 MHz transducer), a mass (arrow) is noted which appears mostly circumscribed with posterior enhancement and could be mistaken for a complicated cyst. (B) Shear-wave elastography, in which low-frequency shear waves are induced in the tissue, shows the lesion to be hard (as evidenced by the orange and red overlay, arrows) compared with the softer (blue) surrounding tissue, suggesting malignancy. This proved to be a fibroadenoma. (Courtesy of Dr Valerie Juhan, MD, Hospital La Timone, Marseille, France, via Super Sonic Imagine, Aix, Provence, France; with permission.)

Fig. 33

A 48-year-old woman with an oval mass on (A) radial (L15-4 MHz transducer) ultrasonography. The margins are mostly circumscribed, and there is a question of a fluid-debris level (arrow), suggesting a complicated cyst. (B) On a shear-wave elastogram, the lesion appears irregular (short solid arrow) and portions are stiff (red). Biopsy showed grade III IDC. (Courtesy of Dr Valerie Juhan, Hospital La Timone, Marseille, France, via SuperSonic Imagine.)

Fig. 34

On sagittal (A) T1- and (B) inversion-recovery weighted MR imaging performed for high-risk screening in a 47-year-old woman with a personal history of contralateral cancer, a smooth round mass with fluid-fluid level is seen (arrows), which is typical of a benign complicated cyst with debris. The more posterior component has a higher protein content than the anterior fluid. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 35

A 30-year-old woman was 24 weeks pregnant and noted a left breast lump. (A) Radial and (B) antiradial ultrasonographic images show a circumscribed oval mass isoechoic to fat with internal echogenic septations (arrowheads). Biopsy showed lactating adenoma. (Courtesy of Dr Ellen Mendelson, Feinberg School of Medicine, Northwestern University, Chicago, IL, via SuperSonic Imagine.)

Fig. 36

A 18-year-old pregnant woman noted a palpable mass in her left breast. On targeted ultrasonography, a circumscribed mass with low-level internal echoes and posterior enhancement was noted, as well as a focal echogenic area representing a fat plug (arrow) in this galactocele, which was aspirated to resolution. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 37

A 36-year-old woman noted a lump 6 months post partum. Targeted (A) radial and (B) antiradial ultrasonography demonstrate nondependent fat-containing echogenic debris (arrows) with fluid-debris level, typical of benign galactocele. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 38

A 36-year-old breastfeeding woman noted a lump. (A) Targeted ultrasonography demonstrated 2 adjacent hypoechoic masses (labeled 1 and 2). Mass 1 appears mostly circumscribed but has internal vascularity on (B) color Doppler. The suspicious nature of these findings was not initially recognized, and the patient was recommended for a 3-month follow-up ultrasonography. (C) On follow-up ultrasonography, both masses had enlarged, and (D) mass 1 was shown to be even more vascular on color Doppler. Ultrasound-guided core biopsy showed grade III IDC from both masses. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 39

A 43-year-old woman had a history of recurrent subareolar abscesses in the left breast. (A) CC mammogram shows a dense oval mass in the subareolar region. (B) Transverse ultrasonography shows a circumscribed oval mass with posterior enhancement at the site of a mammographic and palpable tender mass. Sonographically this mass has the appearance of a complicated cyst with debris. (C) On incision for ultrasound-guided aspiration, pus spontaneously drained from the mass (arrow). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 40

A 64-year-old woman underwent lumpectomy and radiation therapy for tubular cancer. On (A) MLO mammography 18 months after surgery, a circumscribed lucent mass is noted at the lumpectomy site, which is compatible with an oil cyst (arrows). On (B) follow-up MLO mammography 6 months later, the oil cyst is slightly smaller and has developed peripheral rim calcification (arrows). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 41

A 37-year-old woman is 18 months postreduction mammoplasty and noted 2 palpable lumps (marked with radiopaque markers). On close-up (A) CC and (B) MLO mammograms, the masses are shown to be circumscribed and lucent, typical of benign oil cysts (arrows). Ultrasonography was nonetheless performed because of other abnormalities. (C) Transverse and sagittal ultrasonographic images of the mass in the 6-o’clock position show a nearly anechoic mass with thick nodular wall and no posterior features. Without the mammogram, the sonographic appearance would be indeterminate. (E) Radial and (F) antiradial ultrasonographic images of the oil cyst at 12-o’clock position show it to be mostly (but not completely) circumscribed, nearly isoechoic to surrounding fat, and to contain a thin eccentric rim of fluid (arrows). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 42

A 72-year-old woman had a superficial palpable mass. On targeted (A) radial and (B) antiradial ultrasonography, the mass appeared circumscribed but produced minimal low-level echoes. Posterior shadowing (arrows) was evident in (C) fundamental ultrasonographic image without spatial compounding. These features are fundamentally indeterminant on ultrasonography but can be seen with oil cysts, as in this case, which was aspirated, showing red oily fluid. (Courtesy of Dr Valerie Juhan, Hospital La Timone, Marseille, France, via SuperSonic Imagine.)

Fig. 43

(A) A normal terminal duct lobular unit (TDLU) composed of numerous acini lined by bland epithelium. (B) A group of acini are cystically dilated with tall cuboidal epithelium: ie, apocrine metaplasia. When imaged with ultrasonography, the TDLU in B is seen as clustered microcysts. (Reprinted from Warner JK, Kumar D, Berg WA. Apocrine metaplasia: mammographic and sonographic appearances. AJR Am J Roentgenol 1998;170:1375–9; with permission.)

Fig. 44

(A) Radial and (B) antiradial ultrasonographic (10 MHz linear array transducer) images of an incidental mass on baseline screening mammography in a 95-year-old woman show typical appearance of clustered microcysts, one of which appears to contain debris (arrow). (C) Low-power (10× magnification) view of hematoxylineosin staining of 14-gauge core biopsy shows distended acini with tall, cuboidal, apocrine metaplastic epithelium. (Reprinted from Warner JK, Kumar D, Berg WA Apocrine metaplasia: mammographic and sonographic appearances. AJR Am J Roentgenol 1998;170:1375–9; with permission.)

Fig. 45

A 70-year-old ACRIN 6666 participant was noted to have incidental clustered microcysts (arrows) on screening (A) radial and (B) antiradial ultrasonographic images. Ultrasound-guided core biopsy was performed because of diagnostic uncertainty and it showed fibrocystic changes, apocrine metaplasia, cyst wall inflammation, and periductal fibrosis. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 46

A 42-year-old ACRIN 6666 participant was noted to have a mass attributed to clustered microcysts on screening ultrasonography (A, radial and B, antiradial images). At screening ultrasonography 12 months later, ultrasonography of the same area demonstrated a subtle irregular isoechoic mass (arrows) on (C) radial and (D) antiradial images. It seems that the original clustered microcysts resolved and a new lesion has formed. Biopsy showed a 4-mm invasive lobular carcinoma. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 47

A 59-year-old woman who used hormone replacement therapy had a PCPO low-density mass (arrow)in the inner right breast, as seen on (A) spot compression mammographic image. (B) Radial and (C) antiradial targeted ultrasonography (13 MHz linear array transducer) demonstrates an oval circumscribed mass composed of microscopic cysts, that is, clustered microcysts. The mass has been stable for 4 years. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 48

A 62-year-old woman was noted to have loosely grouped punctate calcifications on (A) mediolateral magnification mammogram (arrow). The calcifications were shown to be within clustered microcysts on (B) targeted ultrasonography (arrowheads). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 49

A 49-year-old woman had dense breasts and underwent screening ultrasonography demonstrating multiple bilateral simple and complicated cysts as well as this lesion of clustered microcysts on (A) transverse and (B) sagittal ultrasonographic images. Within 2 years, this mass had resolved on ultrasonography, and other clustered microcysts developed elsewhere over subsequent screening ultrasonographic examinations. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 50

A 54-year-old BRCA mutation carrier was referred for screening MR imaging. (A) On sagittal inversion recovery (STIR) MR imaging, hyperintense fluid-filled clustered microcysts with hypointense thin internal septations were incidentally noted. (B) Close-up. No enhancement was noted after contrast injection. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 51

Ultrasonography was performed to evaluate multiple bilateral small nodules noted on screening mammography in a 58-year-old woman. Multiple cysts were noted. One nodule (A, radial and B, antiradial ultrasonography, thin arrows) was thought to be clustered microcysts but was recommended for a 6-month follow-up ultrasonography. An incidental adjacent complicated cyst with fluid-debris level was noted (arrowhead). At 6-month follow-up (C, radial and D, antiradial ultrasonography), the mass had enlarged. Biopsy was performed showing a 2-cm grade III IDC. The adjacent complicated cyst was stable (arrowhead). In retrospect, the mass is indistinctly marginated with probable solid component on the initial ultrasonographic images (A, B, short fat arrows). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 52

A 78-year-old woman was noted to have a new mass on screening mammography, as seen on (A)CC mammogram (arrow). (B) Targeted ultrasonography demonstrated what appeared to be clustered microcysts (arrow). The patient was not on hormonal therapy. Short-interval follow-up was recommended. At (C) 6-month follow-up ultrasonography, the mass seemed to have thick septations and indistinct margins. Biopsy was recommended, showing grade III IDC with associated high nuclear grade DCIS. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 53

A 31-year-old woman had a mass in the right breast. On (A) radial and (B) antiradial ultrasonography, the mass appeared complex, cystic, and solid with many tiny cystic areas and numerous echogenic microcalcifications (arrowheads). Excision showed benign phyllodes tumor. (Courtesy of Dr Valérie Juhan, La Timone University Hospital, Marseille, France, via SuperSonic Imagine.)

Fig. 54

A 74-year-old woman noted a lump in her left breast. (A) Spot compression mammogram demonstrated a mostly circumscribed dense mass. A portion of the margin appears lobulated (short arrows). Targeted (B) radial and (C) antiradial ultrasonography demonstrated a complex mostly solid mass with eccentric cystic area (arrows). The margins are focally angular (short arrows). Ultrasound-guided biopsy showed grade III IDC. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 55

A 43-year-old woman felt a lump, which corresponded to a dense, slightly indistinctly marginated mass on spot compression (A) XCCL and (B) MLO mammograms (arrows). Targeted (C) sagittal and (D) transverse ultrasonography (L17-5 MHz transducer) showed a complex cystic and solid mass. The mass was found to have internal vascularity on (E) sagittal and (F) transverse power Doppler ultrasonographic images. Repeat (G) radial and (H) transverse ultrasonography at the time of biopsy 2 weeks later (L12-5 MHz transducer) showed the mass to have thick walls. Ultrasound-guided 14-gauge core biopsy showed grade III IDC. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 55

A 43-year-old woman felt a lump, which corresponded to a dense, slightly indistinctly marginated mass on spot compression (A) XCCL and (B) MLO mammograms (arrows). Targeted (C) sagittal and (D) transverse ultrasonography (L17-5 MHz transducer) showed a complex cystic and solid mass. The mass was found to have internal vascularity on (E) sagittal and (F) transverse power Doppler ultrasonographic images. Repeat (G) radial and (H) transverse ultrasonography at the time of biopsy 2 weeks later (L12-5 MHz transducer) showed the mass to have thick walls. Ultrasound-guided 14-gauge core biopsy showed grade III IDC. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 56

A 55-year-old woman had reduction mammoplasty 3 months earlier. The patient then noted a lump in the lower inner left breast. The lump corresponded to a dense irregular mass on (A) CC and (B) MLO mammograms (arrows). (C) Radial and (D) antiradial targeted ultrasonography demonstrate a thick-walled complex cystic mass with thick internal septations, compatible with postoperative seroma or hematoma. Track to overlying skin incision was evident (arrow). The mass decreased on a 6-month follow-up. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 57

A 51-year-old woman had lumpectomy for cancer 2 years earlier. The thick-walled collection with thick internal septations seen on (A) radial and (B) antiradial ultrasonographic images is consistent with postoperative seroma or hematoma. With careful technique, the track to the overlying skin incision can be demonstrated (arrows), thus helping to confirm this impression. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 58

A 52-year-old woman had screening MR imaging preoperatively after a recent result of atypical lobular hyperplasia on core biopsy. On (A) sagittal STIR image, multiple cysts are demonstrated, some of which are proteinaceous with decreased signal intensity. One cyst in the upper central breast (arrow) showed a slow persistent smooth thin (<2 mm) rim of enhancement on (B) sagittal fat-suppressed spoiled gradient echo T1-weighted image obtained 2 minutes after intravenous injection of 0.1 mmol/kg gadolinium-based contrast (arrow). This appearance is typical of a ruptured or inflamed cyst and does not require intervention. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 59

A 52-year-old woman noted a lump in her left breast. On (A) spot magnification CC mammography, the mass was found to be dense, with unusual amorphous coalescent calcifications and indistinct margins. On (B) sagittal STIR MR images, the lump appeared as a partially cystic mass (arrow) which was peripherally hypointense, probably due to the calcification. On (C) 3-dimensional fat-suppressed spoiled gradient echo MR imaging 1.5 minute after injecting 0.1 mmol/kg of gadolinium-based contrast, the mass showed nodular, thick, rim enhancement with washout kinetics. Ultrasound-guided core biopsy and excision showed metaplastic sarcoma with osteo-chondritic calcification or ossification involving a phyllodes tumor. (D) Gross of histopathology confirms the presence of fluid-filled spaces (arrows), which surrounded leaf-like outgrowths of the phyllodes tumor. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 60

Acute blood has a characteristic bright signal on (A) axial T1-weighted images and appears hypointense on (B) sagittal STIR images as in the case of a 77-year-old woman with a large hematoma (arrows) imaged 1 week after stereotactic core biopsy for DCIS. The seroma portion follows typical fluid signal characteristics (ie, hypointense on T1 and hyperintense on STIR images). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 61

A 50-year-old woman had a palpable mass in the right breast. (A) Transverse and (B) sagittal ultrasonographic images demonstrate a complex cystic and solid mass with thick wall (arrowheads) and possible intracystic mass (arrows). Ultrasound-guided 14-gauge core biopsy showed ruptured cyst with inflammation. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 62

A 42-year-old woman had screening MR imaging demonstrating a rimenhancing mass. (A) Targeted ultrasonography showed a thick-walled cystic mass with possible intracystic mass (arrow). Ultrasound-guided aspiration was performed to resolution, showing (B) cloudy yellow fluid typical of benign cyst content and with visible cholesterol crystals (arrows). Because the fluid was typical of benign cyst content, it was discarded. Taking together imaging findings and results of aspiration, the mass is consistent with a ruptured or inflamed cyst. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 63

A 76-year-old woman had a palpable mass in the right breast at the 9-o’clock position 1 cm from the nipple. (A) Spot compression CC mammogram demonstrates a circumscribed, gently lobulated mass with coarse calcification (arrow). Targeted (B) radial and (C) antiradial ultrasonography demonstrates an intracystic or thick-walled mass with angular margins (arrows). Biopsy showed DCIS in a papillary lesion. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 64

A 75-year-old woman noted a palpable mass. On (A) targeted ultrasonography, a complex cystic and solid mass was noted with a frondlike appearance to the intracystic mass (long arrow). A vascular stalk (short fat arrow) was noted to the intracystic mass, and the wall was focally thickened (arrowheads). (B) Gross specimen demonstrates the intracystic mass (arrow). Histopathology showed in situ papillary carcinoma, which was focally invasive where the wall was thickened. (Courtesy of Dr Eva Gombos, Brigham and Women’s Hospital, Boston, MA.)

Fig. 65

An 81-year-old woman was noted to have a dense round mass on (A) screening mammography (arrow). (B) Targeted ultrasonography demonstrated a small intracystic mass (arrow). The mass was aspirated and was thought to resolve, but the mass was found to recur on 12-month follow-up (C) mammography and (D) ultrasonography (arrows). Biopsy was then performed, showing mucinous carcinoma (a special type of well-differentiated invasive ductal carcinoma). (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 66

A 45-year-old woman with prior history of fibroadenoma at 12-o’clock position in the left breast had an enlarging circumscribed mass in the lower inner left breast on screening (A) CC and (B) MLO (arrows). Targeted (C) radial and (D) antiradial ultrasonography demonstrated an isoechoic oval mass (arrows) with small eccentric cystic areas (arrowheads), that is, a complex cystic and solid mass. Ultrasound-guided 14-gauge core biopsy confirmed a complex fibroadenoma with usual duct hyperplasia and cystic areas. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)

Fig. 67

A 75-year-old ACRIN 6666 participant was noted to have a complex predominantly solid mass on the third annual screening (A) radial and (B) antiradial ultrasonography. Ultrasound-guided core biopsy and excision showed benign papilloma. (Courtesy of Wendie A. Berg, MD, PhD, Lutherville, MD.)