Post on 25-Jan-2017
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