Imaging classification and BIRADS assessment of cystic breast lesions with pathologic correlates. a 5-year experience in Zaria, North West Nigeria.

Background: Breast cysts encompass a variety of pathologies, both benign and malignant. Therefore, classifying cysts into different categories is needful to develop a management algorithm. This study aimed to describe and distinguish between simple, complicated and complex cysts; and compare the final BIRADS assessment with pathologic findings. Materials and methods: A 5-year retrospective review of our ultrasound database identified two hundred and seventy patients with cystic breast lesions. They were divided into simple, complicated and complex cysts according to ultrasound characteristics based on shape, orientation, margin, wall thickness, internal features (echogenicity, septa, mass) posterior acoustic features, surrounding tissue vascularity. The final BIRADS assessment was correlated with histological findings. Results: There were two hundred and sixty-six (98.5%) females and four (1.5%) males with a mean age 34.9 ± 11.8 years. The commonest presentation was a palpable mass, in 70% of the patients. There were 89 (33.0%) simple cysts, 61 (22.6%) complicated cysts and 120 (44.4%) complex cysts. Conclusion: Majority of the breast cysts (83%) were benign with overall 17% incidence of malignancy. Complex cysts were the most frequent cyst type in our study, it is also the category most frequently associated with breast cancer, obviating the need for histology.

Breast hydatid cyst presented as a fluctuant painless lump mimicking galactocele: A case report.

Hydatid disease is a zoonosis caused by the Echinococcus species. The liver and lungs are where it generally seen, with breast involvement being extremely uncommon. This is a case of a woman aged 28 years who presented with a progressive painless swelling on the left breast, which was fluctuant and nontender, detected on the upper outer quadrant. The cytologic evaluation yielded a crystal-clear fluidal aspirate composed of a few laminated metachromatic materials and the mass sonographically appeared as an anechoic cystic mass having a double-layered wall with posterior acoustic enhancement. A radical pericystectomy was performed after the preoperative diagnosis of breast hydatid cyst was entertained, and the diagnosis was later confirmed by histopathology. Although isolated breast hydatid cysts are uncommon, they can happen and may mimic other cystic and solid masses of the breast clinically. Thus, radiologic assessment with cytopathologic correlation is imperative for precise preoperative diagnosis and to minimize the risk of intraoperative complications.

A rare case of persistent large cystic breast tumor mimicking as malignant cystic breast cancer.

Breast cyst, especially galactocele is usually benign. Needle aspiration or surgical removal are both diagnostic and therapeutic. Mastectomy is not necessary even if the whole breast is affected, but surgeons need to be vigilant. We describe a rare case of persistent and large breast cyst.

Crystallizing galactocele of the breast masquerading as a malignancy: Report of a rare case with cytological diagnosis.

Galactoceles are the common benign cystic breast lesions during pregnancy and lactation. This report describes the cytological findings of a case of long standing galactocele which underwent crystallization and mimicked carcinoma clinically as well as on sonography. A young woman presented with a hard painless lump in the right breast. She noticed the lump during her pregnancy 2.5 years back. Clinically the lesion was hard and sonography was equivocal in categorizing the lesion. An FNAC was performed which showed granular amorphous material along with crystals of various shapes and sizes. A diagnosis of crystallizing galactocele was made and woman was assured about the benign nature of the lesion. The cytological findings of crystallizing galactocele have been reported in very few cases. In the present case, a detailed history and clinical examination followed by fine needle aspiration established the diagnosis of crystallizing galactocele.

Prevalence of underlying malignancies in complex cysts of the breast.

INTRODUCTION: The management of complex cysts of the breast is an ongoing topic of discussion. The aim of this study was to determine the prevalence of underlying malignancy in radiologically diagnosed complex cysts, and to assess whether watchful waiting could be the preferred method to safely manage complex cysts of the breast. SUBJECTS AND METHODS: A single-center retrospective study was performed between May 2003 and November 2019 in the VieCuri Medical Centre. Women with a radiologically diagnosed complex cyst of the breast were included. Prevalence of underlying malignancy was calculated, as were absolute risk reduction and number needed to treat in order to diagnose malignancy. In addition, patient characteristics were compared to determine characteristics associated with malignancy. RESULTS: Of 78 radiologically diagnosed complex cysts of the breast, five (6,4%) were found to be malignant. The number needed to treat was calculated at 12,8 (absolute riks reduction 0,078). Age (P = 0,003) was associated with malignancy. CONCLUSION: Complex cysts of the breast could be managed more conservatively. Patient characteristics can be used to assess the eligibility for radiological follow-up. This, in turn, would lead to a lower NNT and possibly a decrease in disease burden and healthcare costs.

Carcinoma medular con degeneración seudoquística: reporte de un caso / Medullary carcinoma with pseudocystic degeneration: case report

INTRODUCCIÓN: El carcinoma medular es diagnosticado en aproximadamente del 1 al 7% de todos los cánceres mamarios y existen pocos casos asociados a una lesión quística. CASO CLÍNICO: Femenino de 34 años con diagnóstico de quiste complejo de mama derecha; histopatológicamente se reporta carcinoma medular en una de las paredes del quiste. CONCLUSIONES: Los tumores malignos de mama en formas quísticas han sido descritos en un 0,3-7%, y pocas veces son carcinomas medulares

INTRODUCTION: Medullary carcinoma is diagnosed in approximately 1% to 7% of all breast cancers and has been rarely associated with a cystic lesion. CASE REPORT: A 34-year-old woman was diagnosed with a complex cyst of the right breast. Histopathological analysis identified medullary carcinoma in one of the walls of the cyst. CONCLUSIONS: Malignant tumours of the breast are rarely found in cystic forms. Only 0.3% to 7% of breast cancer cases have been reported as medullary carcinomas

Clustered Microcysts at Breast US: Outcomes and Updates for Appropriate Management Recommendations.

Background Clustered microcysts are common, especially in perimenopausal women, and are seen in up to 6% of US examinations. However, there are limited published data on appropriate assessment and management recommendations for clustered microcysts on breast US images. Purpose To determine outcomes of lesions identified as clustered microcysts on breast US images to help guide appropriate management recommendations. Materials and Methods Lesions classified as clustered microcysts at breast US were retrospectively identified in women at two hospitals (a large tertiary care academic hospital and a National Comprehensive Cancer Network-designated comprehensive cancer center) within one metropolitan health system from 2005 through 2015. If US-guided tissue sampling was performed, results were obtained from the pathology or cytology reports. If sampling was not performed, only lesions with at least 24 months of imaging follow-up or any imaging follow-up with interval resolution or decrease in size were included in the study. Data were evaluated using standard statistics, Fisher exact tests, and Wilcoxon rank sum tests. Results A total of 189 women (median age, 52 years [interquartile range, 46-59 years]) with 196 lesions classified as clustered microcysts on US images were included in this study. During the surveillance period of at least 24 months and at tissue diagnosis, malignancy was not found in any of the 196 lesions (0%) (95% confidence interval: 0.0%, 1.9%). A total of 158 of 196 (80%) lesions were followed with imaging, and 38 of 196 (20%) lesions underwent percutaneous sampling. During the follow-up period, 28 of 158 (18%) lesions spontaneously resolved, 13 of 158 (8%) decreased in size, and one of 158 lesions (0.6%) increased at 18-month follow-up but then became stable. One hundred sixteen of 158 lesions (73%) demonstrated no change at follow-up imaging, 38 of 196 (19%) lesions underwent percutaneous sampling, and 38 of 38 (100%) revealed benign results. Conclusion No malignancies were identified in this series. These results further support the existing literature that lesions characterized as clustered microcysts demonstrate a very low risk of malignancy and can be classified as benign. Biopsy may be safely avoided. © RSNA, 2020 See also the editorial by Berg in this issue.

Ultrasound Findings in Three Complex Cystic Breast Carcinomas: Correlation with Intrinsic Tumor Subtype.

In ultrasound examinations, mixed mammary gland masses are divided into either intracystic masses that contain a solid component in the cyst or solid masses that contain a fluid component in the mass. The histological types and subtypes of three complex cystic masses that showed different internal compositions in ultrasound were determined using the ultrasound findings of three patients. Case 1: The mass showed a large cystic component (bleeding) inside and a broad-based solid lesion at the margin in the ultrasound finding. The histological type was encapsulated papillary carcinoma and the subtype was luminal A. Case 2: The mass was lobulated with a small cystic component at the margin. The histological type was solid papillary carcinoma and the subtype was luminal A. Case 3: The mass was lobulated with a circumscribed margin. Cystic components suspected of being hemorrhagic necrosis were observed at the margin and within the solid component. The histological type was squamous cell carcinoma and the subtype was triple negative. Case 2 was a solid mass in appearance, but a cystic component noted at the margin was possibly an intracystic mass. For Case 3, findings suggestive of necrosis were observed both at the margin and in the solid component and this suggested a mass with fluid degeneration. Complex cystic masses are usually examined with a focus on the solid component seen on ultrasound images; however, it is also important to observe the cystic composition. This can help determine the subtypes in addition to the histological types.

Cholesteroloma of the breast: A 10 year retrospective review of 79 cases with radiology correlation.

A cholesteroloma or cholesterol granuloma of the breast is an uncommon lesion representing an inflammatory/reactive process with unclear etiology. In this study, we reviewed our 10-year experience with cholesteroloma of the breast with clinical, radiologic, and histopathological correlation. Seventy-nine cases were selected. The mean patient age was 57.7 (range 25-90) years old. Patients had hypercholesterolemia with mean blood cholesterol level of 201 mg/dL (P < 0.001). The mean body mass index (BMI) was 26.7 kg/m2 (P = 0.1976). The indications for the breast biopsies were mass lesion on radiology (85.5%, n = 65) and microcalcifications (10.5%, n = 8). Of the 65 cases of the mass lesions, 52 presented as solid masses and 13 were cystic. On the diagnostic mammogram or ultrasound, 81.9% were BI-RADS 4% and 6.9% were BI-RADS 5. Macrocysts were the most common pathological finding associated with cholesteroloma suggesting the etiology of cholesteroloma may be the result of repair process from obstruction and rupture of the macrocysts. Six cases (9.2%) of cholesterolomas had persistent masses during follow-up. The recognition of this lesion and radio-pathological correlation can help us better understand this entity and distinguish it from its mimickers.

A 10 year retrospective review of fine needle aspiration cytology of cystic lesions of the breast with emphasis on papillary cystic lesions.

BACKGROUND: Fine needle aspiration cytology (FNA) is a simple, safe, cost effective, and accurate method for diagnosis of cystic lesions of the breast. Our study aims to correlate FNA cytology of cystic lesions of the breast with the histologic diagnosis. METHODS: During a period of 10 years (2007-2017), 314 cases of breast cystic lesions were retrieved from a total 1073 cases of breast FNAs. Of these, 78 cases from 77 patients (mean age = 54.6, female: male = 76:1) with simultaneous FNA and core needle biopsy (CNB) and/or excision specimen were reviewed. The FNA cytology reports were correlated with the histology results of CNB (n = 72) and breast excision (n = 20). RESULTS: Overall, 73 of 78 (93.6%) FNA cases were concordant with CNB and/or excision results. Fifty-five benign FNAs were all concordant with histology and reported as benign (negative predictive value = 100%). The positive predictive value of FNA with a malignant diagnosis was 100%, 71.4% for a suspicious diagnosis, and 33.3% for atypical cytologic diagnosis. Two of six papillary lesions were discordant with the concurrent CNB, but the FNA results were concordant with the final histology on excision. CONCLUSIONS: FNA allows accurate diagnosis of benign cystic lesions. FNA also plays a prominent role in evaluating cystic papillary lesions of the breast and helps to prevent false negative results on the simultaneous CNB. It is essential that FNA and CNB diagnoses be used in combination to make the correct diagnosis and for clinical management.

Galactocele of adult male breast: A cytopathologist's perspective.

Galactocele, although a common cytological diagnosis in females, is not previously reported as a cause of breast enlargement in adult males. Hyperprolactinemia is the principal cause of galactocele in male breast. Besides drug induced hyperprolactinemia, other anatomical lesions of hypothalamo-pituitary region and different medical conditions like cirrhosis and chronic kidney disease are to be considered along with a full evaluation of features revealing hypogonadism in case of galactocele. Aspirated milk from the male breast is the primary clue for this detailed investigation process. Here we are presenting the first case of galactocele of the male breast due to hypogonadotropic hypogonadism with idiopathic hyperprolactinemia.

Breast Cyst Fluid Analysis Correlations with Speed of Sound Using Transmission Ultrasound.

RATIONALE AND OBJECTIVES: The purpose of this work is to determine if the speed of sound value of a breast cyst can aid in the clinical management of breast masses. Breast macrocysts are defined as fluid-filled tissue masses >1 cm in diameter and are thought to be aberrations of normal development and involution, often associated with apocrine metaplasia. The benign natural history of breast cysts is well known, and it is important to obtain high specificity in breast imaging to avoid unnecessary biopsies in women who have benign diseases, particularly those with dense breast tissue. Transmission ultrasound is a tomographic imaging modality that generates high-resolution, 3D speed of sound maps that could be used to identify breast tissue types and act as a biomarker to differentiate lesions. We performed this study to investigate the microanatomy of macrocysts observed using transmission ultrasound, as well as assess the relationship of speed of sound to the physical and biochemical parameters of cyst fluids. MATERIALS AND METHODS: Cyst fluid samples were obtained from 37 patients as part of a case-collection study for ultrasound imaging of the breast. The speed of sound of each sample was measured using a quantitative transmission ultrasound scanner in vivo. Electrolytes, protein, cholesterol, viscosity, and specific gravity were also measured (in the aspirated cyst fluid) to assess their relationship to the speed of sound values obtained during breast imaging. RESULTS: We found positive correlations between viscosity and cholesterol (r = 0.71) and viscosity and total protein × cholesterol (r = 0.78). Additionally, we performed direct cell counts on cyst fluids and confirmed a positive correlation of number of cells with speed of sound (r = 0.74). The speed of sound of breast macrocysts, as observed using transmission ultrasound, correlated with the cytological features of intracystic cell clumps. CONCLUSION: On the basis of our work with speed as a classifier, we propose a spectrum of breast macrocysts from fluid-filled to highly cellular. Our results suggest high-speed cysts are mature macrocysts with high cell counts and many cellular clumps that correlate with cyst microanatomy as seen by transmission ultrasound. Further studies are needed to confirm our findings and to assess the clinical value of speed of sound measurements in breast imaging using transmission ultrasound.

[The value of ultrasound classification in BI-RADS category 4 of breast complex cystic masses].

Objective: To analyze the feature of breast complex cystic masses and to classify it at ultrasonography (US), which applied to the Breast Imaging Reporting and Data System (BI-RADS) categories 4a to 4c with pathological results as the golden standards. Methods: The ultrasonographic data and clinical features of 78 patients with complex cystic masses confirmed by pathology in Cancer Hospital from July 2014 to June 2017 were retrospectively reviewed. The complex cystic breast masses were divided into four classes on the basis of their US features: type 1 [thick wall and (or) thick septa (> 0.5 mm)], type 2 (one or more intra-cystic masses), type 3 (mixed cystic and solid components with cystic components more than 50%) and type 4 (mixed cystic and solid components with solid components more than 50%). Positive values (PPVs) were calculated for each type. Multiple linear regression analysis was used to analyze the ultrasonographic features of the masses (lesion size, margins, blood flow resistance index, calcification, and axillary lymph nodes, etc.) with malignant correlation. Results: There were 81 lesions in 78 patients. Among the 81 masses based on US appearance, 14 (17.3%) were classified as type Ⅰ, 18 (22.2%) as type Ⅱ, 18 (22.2%) as type Ⅲ, and 31 (38.3%) as type Ⅳ. The positive predictive values of the malignant lesions of type Ⅰ, type Ⅱ, Ⅲ and Ⅳ were 7.1%, 16.7%, 61.1% and 48.3%, respectively (P=0.040). In all the 81 masses, 14 were BI-RADS categories 4a, 18 were BI-RADS categories 4b and 49 were BI-RADS categories 4c. Masses with maximum diameter equal to or larger than 2.0 cm, unclear margins, RI≥0.7 and presence of abnormal axillary nodes assessment had a high probability of malignancy (P=0.030, 0.038, <0.001 and 0.025, respectively). Conclusion: Ultrasound typing is helpful for differentiating benign and malignant breast complex cysts and classifying BI-AIDS 4a to 4c, thus providing clearer treatment for clinical practice.

Surgery for giant tumours of the breast: a 15 year review.

BACKGROUND: Giant tumours of the breast tend to occur in the adolescent age group. Racial predilection has been noted in the literature. The mass often occupies most of the breast, leading to its distortion. Many authors have advocated a mastectomy for benign tumours that severely distort the breast. Giant benign tumours when treated by simple excision risk persistence of asymmetry. To avoid this asymmetry, some authors have resorted to excision and immediate reduction mammaplasty. The aim of this retrospective study was a report on giant tumours of the breast presenting to a plastic surgery unit and to analyse demographic factors, clinical presentations, tumour pathology, management, complications, as well as patient and breast outcomes. METHODS: Medical records of patients with giant tumours were retrospectively analysed for assessing demographic factors, clinical presentation, tumour pathology, the technique of surgery performed and patient and breast outcomes in a single hospital setting. Breast outcomes were rated by panel of 4 experienced plastic surgeons using the 4 Point Likert scale. Their ratings were statistically analysed for inter-rater agreement. RESULTS: Twenty-three subjects were identified to have giant tumours of the breast. Of these South African patients, 19 were black, 3 were Indian and 1 was of mixed ethnicity. The age range was 12-49 years (y) with an average of 19y. All masses were palpable. The final pathological diagnosis was fibrocystic disease in 3, giant fibroadenoma in 14, phyllodes tumour in 4, and hamartoma in 2. The size range was 10-45 cm with a median size of 18 cm. All but one patient had simple excision followed by immediate reduction mammaplasty. Twenty patients were assessed after operation. A minimum of 1 to a maximum of 4 patients per reviewer showed unsatisfactory outcomes and a minimum of 18 to a maximum of 21 patients per reviewer showed satisfactory to excellent outcomes. The overall agreement between assessors for this was 84%. CONCLUSION: Benign giant tumours (> 10 cm) of the breast are suitably managed by excision of the mass and a reduction mammoplasty technique of reconstruction.

Estrogen Receptor-α and Progesterone Receptor Expression in Mammary Proliferative Lesions of Female Pet Rabbits.

In breast cancer of women, the estrogen receptor-α (ERα) and progesterone receptor (PR) status has prognostic and therapeutic significance. The aim of this study was (1) to characterize by immunohistochemistry the expression of ERα and PR in nonneoplastic and neoplastic mammary gland tissue of pet rabbits and (2) to correlate the ERα/PR status and histological features. All 124 rabbits included in this study had a mammary tumor; in addition, 2 rabbits had lobular hyperplasia and 25 had multiple cysts. Of the 124 neoplasms, 119 (96%) were carcinoma, 2 (2%) were carcinoma in situ, and 3 (2%) were adenoma. ERα or PR or both were detected in 2 of 2 carcinomas in situ, 3 of 3 adenomas, 19 of 25 cysts, and 2 of 2 lesions of lobular hyperplasia. Most carcinomas (75/119, 63%) were negative for both ERα and PR; 22 of 119 carcinomas (18%) were double-immunopositive. The ERα and PR expression was not influenced by histotype or histological tumor grade. In carcinomas, there was a statistically significant correlation between increased mitotic count and reduced expression of ERα and PR, and the mitotic count was higher in double-immunonegative carcinomas (75/119). The findings suggest that in rabbit mammary carcinomas, proliferative activity is mainly influenced by factors other than estrogen and progesterone and provides the basis for future investigations into the prognostic significance of the ERα and PR status of mammary tumors.

Crystallizing Galactocele: A rare entity-report of two cases.

Galactocele is a common lesion occurring during pregnancy or lactation. It is a benign cystic breast lesion containing milk. On Fine Needle Aspiration Cytology, milky fluid is aspirated, and cytology shows paucicellular aspirate with foamy macrophages and occasional apocrine cells in a proteinaceous fluid background. Rarely, the contents of galactocele can crystallize giving rise to an entity of crystallizing galactocele. Crystallizing galactocele is a rare entity, and to the best of our knowledge, less than 10 cases have been reported in the literature.

Galactocele, Pitfall for the Evaluation by 18F-FDG PET/CT.

A high F-FDG uptake was found in mammary lesions in a 36-year-old woman who underwent a PET/CT scan for initial staging of diffuse large B-cell lymphoma. The patient has given birth 2 months ago and was breastfeeding. Ultrasound-guided fine-needle aspiration of 1 lesion yielded creamy liquid consistent with milk and confirmed the diagnosis of galactocele.

Intracystic breast carcinoma. An important differential diagnosis in postmenopausal patients presenting with a rapidly growing breast cyst. Management and literature review.

Intracystic breast carcinoma is a rare clinical entity accounting for 0.5-2% of all breast cancers. It represents a distinctive clinical form rather a histological subtype of breast cancer and can either be in situ or invasive tumor. We herein describe a rare case of intracystic breast carcinoma arising from the wall of a cyst in a postmenopausal patient, who presented with a rapidly growing complex breast cyst. Diagnostic evaluation and management of the patient are discussed along with a review of the literature. Complex breast cysts may represent a diagnostic and therapeutic challenge. An underlying malignancy has been reported in 21-31% of the cases. Preoperative diagnosis is challenging. Complex breast cysts with thick wall, thick inner septations, and intracystic solid components should undergo histological evaluation in order to rule out an underlying malignancy. The cytological analysis may be inconclusive. Ultrasound-guided biopsy is the diagnostic modality of choice. The correlation of clinical features, with imaging and histopathological findings is very important for the optimal treatment. In cases of discordance, a complete surgical excision is necessary with careful assessment of the extent of the disease and appropriate treatment.

Cytological diagnosis of crystallizing galactocele - report of an unusual case.

Crystallizing galactocele is a very rare entity which yields a viscous, chalky material on Fine Needle Aspiration Cytology (FNAC). FNAC is used both for diagnosis as well as treatment of this condition. We present here a case of 26 years old lactating female who presented with swelling in the right breast for 8 months. The swelling was firm, discrete, non-tender and mobile involving the upper inner quadrant of right breast. A diagnosis of benign breast disease, possibly fibroadenoma was made clinically. FNAC of the lesion yielded thick, milky and chalky material. Cytological smears showed numerous semitransparent crystals of varying size and shapes with angulated borders in a background of granular and amorphous debris along with frothy appearing micelles. These crystals show positive birefringence. Based on clinical history of lactation and typical cytological findings, a diagnosis of crystallizing galactocele was made. We report this case because of rarity of this condition and to the best of our knowledge, till date only five cases of crystallizing galactocele has been reported in medical literature.