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Article

Sonographic Differentiation of
Benign and Malignant Cystic
Lesions of the Breast
Yun-Woo Chang, MD, PhD, Kwi Hyang Kwon, MD, Dong Erk Goo, MD,
Deuk Lin Choi, MD, Hye Kyung Lee, MD, Seung Boo Yang, MD

Objective. The purpose of this study was to subdivide the types of sonographic findings of benign ver-
sus malignant cystic masses and to determine appropriate patient care according to the sonographic
findings with pathologic correlation. Methods. The sonographic findings of 175 symptomatic cystic
breast lesions were pathologically proven and reviewed retrospectively. Cystic lesions were classified as
6 types: simple cysts (type I), clustered cysts (type II), cysts with thin septa (type III), complicated cysts
(type IV), cystic masses with a thick wall/septa or nodules (type V), and complex solid and cystic mass-
es (type VI). Sonographic findings were compared with the pathologic results and were evaluated
according to the incidence of benign and malignant masses. Results. All 23 type I, 15 type II, 22 type
III, and 35 type IV cases were pathologically proven to be benign. Seven (25.9%) of the 27 type V cases
and 33 (62.3%) of the 53 type VI cases were proven to be malignant. We analyzed the shapes and
margins of 80 cases of cystic masses with a solid component (types V and VI); 16 (44%) of 36 sono-
graphically circumscribed masses were malignant. Conclusions. Because the sonographically detected
simple cysts (type I), clustered cysts (type II), and cysts with thin septa (type III) were all benign, annual
routine follow-up appears reasonable. Symptomatic complicated cysts (type IV) should be aspirated
and appropriately treated according to clinical symptoms. Cystic masses with a solid component (types
V and VI) should be examined by biopsy with pathologic confirmation. Key words: breast; cystic mass;
sonography.

B
Abbreviations
BI-RADS, Breast Imaging Reporting and Data System
Received June 21, 2006, from the Department of
Radiology, College of Medicine, Soonchunhyang
University Hospital, Seoul, Korea (Y.-W.C., K.H.K.,
D.E.G., D.L.C.); Department of Radiology,
Soonchunhyang University Hospital, Bucheon,
Korea (H.K.L.); and Department of Radiology,
Soonchunhyang Hospital, Gumi, Korea (S.B.Y.).
Revision requested July 11, 2006. Revised manuscript
accepted for publication August 23, 2006.
We thank Bonnie Hami (Department of Radiology,
University Hospital of Cleveland, Cleveland, OH) for
editorial assistance.
Address correspondence to Yun-Woo Chang, MD,
PhD, Department of Radiology, Soonchunhyang
University Hospital, 22 Dasagwan-gil, Yongsan-ku,
Seoul 140-743, Korea.
E-mail: ywchang@hosp.sch.ac.kr
reast cysts, including simple cysts, are common
findings in women older than 40 years who have
undergone sonography. Simple cysts have no
potential malignancy, but solid and cystic masses
may cause diagnostic dilemmas.1,2 Various types of cystic
lesions of the breast have been described by Berg et al1;
complex cystic lesions were proven malignant in 23% of
the patients in their study. Intracystic carcinomas of the
breast are rare entities that constitute 0.3% to 2.0% of all
breast carcinomas, and the solid portion may be quite
large at the time of diagnosis.3 We attempted to classify
the types of sonographic findings of symptomatic cystic
lesions of the breast and correlated these findings with
the pathologic results. We tried to evaluate the character-
istic features of benign versus malignant cystic masses
and to determine appropriate patient care according to
the sonographic findings.

© 2007 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2007; 26:47–53 • 0278-4297/07/$3.50
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Benign and Malignant Cystic Lesions of the Breast
Materials and Methods
From June 2002 through March 2006, during
which time 57,437 female patients underwent
sonography of the breast at our institution, we
determined that 212 symptomatic patients had
cystic breast masses. One hundred seventy-five
patients with breast cystic masses were patho-
logically confirmed, and 37 patients with cysts
were followed without pathologic confirmation
during the following 4 years by 3 to 4 subse-
quent sonographic examinations. Recording and
reviewing the results of these examinations and
the results of subsequent imaging, clinical, and
pathologic follow-up was approved by our insti-
tutional database. Pathologic confirmation was
performed by fine-needle aspiration (n = 123),
core needle biopsy (n = 39), or excision (n = 13).
All patients had symptoms such as a palpable
mass, a lump, breast pain, nipple discharge, or a
red skin change. The mean age of the patients
was 44.6 years (range, 15–73 years). The mean
diameter of the lesions was 25 mm (range, 7–140
mm). Diagnosis was established with aspiration
using an 18- to 20-gauge needle in 123 lesions
from which fluid was sent for cytologic examina-
tion and was followed by core needle biopsy or
excision in 57 lesions because of the persistent
existence of a solid component. Sonographically
guided core needle biopsy was performed in
39 lesions with a 14-gauge automated biopsy
gun (Pro-Mag 2.2; Manan Medical Products,
Northbrook, IL), and excision biopsy was per-
formed in 13 lesions. Sonography was per-
formed by a physician using a broad-bandwidth
linear array transducer with a center frequency
of 10 MHz supplemented by a transducer with a
center frequency of 7.5 MHz (LOGIQ 700 Expert
Series; GE Healthcare, Milwaukee, WI; or HDI
5000; Philips Medical Systems, Bothell, WA).
Cystic lesions were classified into 6 types (types
I–VI), which were slightly modified from those
mentioned in an article by Berg et al1 (Figure 1).
Simple cysts (type I) were defined as anechoic
masses with an imperceptible, circumscribed
border and acoustic enhancement. Clustered
cysts (type II) were defined as clustered anechoic
cysts with no discrete solid components. Cysts
with thin septa (type III) were defined as cysts
within septa of less than 0.5 mm in thickness.
48
Figure 1. Subtypes of cystic masses of the breast. Type I indicates
simple cyst; type II, clustered cysts; type III, cyst with thin septa;
type IV, complicated cyst; type V, cyst with a thick wall/septa or
nodules; and type VI, complex solid and cystic mass.
Complicated cysts (type IV) were defined accord-
ing to the American College of Radiology Breast
Imaging Reporting and Data System (BI-RADS)4
as lesions with homogeneous low-level echoes
that otherwise meet the criteria of simple cysts,
including cystic lesions containing fluid-debris
levels or floating echogenic debris. Cystic masses
with septa or a wall greater than 0.5 mm in thick-
ness or mixed cystic and solid masses with at
least a 50% cystic component were classified as
cystic masses with a thick wall/septa or nodules
(type V). Primarily solid masses with eccentric
cystic foci were considered complex solid and
cystic masses (type VI).
Two expert radiologists classified the types of
cystic breast lesions according to the sonograph-
ic findings in consensus. The sonographic find-
ings of each type of cystic breast lesion were
compared with the pathologic results and were
evaluated according to the incidence of benign
and malignant masses. We analyzed the shapes
and margins of the cystic lesions with solid com-
ponents as 2 types of type V (cystic mass with a
thick wall/septa or nodules) and type VI (complex
solid and cystic masses) and correlated with the
pathologic results. Ninety-four lesions, including
37 lesions classified as sonographic type I lesions
without pathologic confirmation, were then fol-
lowed 1 to 5 times during the next 45 months.
Results
In Table 1, the classifications and methods of
examination are summarized. Among 175 lesions,
23 type I cases, 15 type II cases, 22 type III cases,
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Chang et al

and 35 type IV cases were proven to be benign.

Seven type V cases and 33 type VI cases were
proven to be malignant.
All 23 type I, 15 type II, and 22 type III cases
were pathologically confirmed as cysts or fibro-
cystic disease (Figures 2 and 3). One type I case
and 1 type III case were confirmed as fat necro-
sis, and 1 type III case was proven to be a muco-
celelike tumor. Thirty-five cases with the
sonographic appearances of type IV were proven
to be benign, including 4 cysts, 9 fibrocystic
changes, 21 abscesses, and 1 mucocelelike
tumor (Figure 4). All cases had symptoms, for
Figure 2. Transverse sonogram from a 39-year-old woman with
example, a palpable mass, breast pain, or skin
nipple discharge shows aggregate cysts of various diameters but
redness. Twenty-one cases were confirmed as without a discrete solid component, classified as type II (arrow-
abscesses by fine-needle aspiration or biopsy. heads). Aspiration cytologic examination revealed a fibrocystic
Subsequent excision and drainage were per- change.
formed after antibiotic treatment. Among the 27
cases of type V cystic masses, 20 (74.1%) were
proven to be benign (3 cysts, 3 fibrocystic were composed of palpable masses, including
changes, 7 abscesses, 2 mucocelelike tumors, 1 those in 6 patients with breast pain and in 2
fibroadenoma, and 4 papillomas), and 7 (25.9%) patients with bloody nipple discharge. When
were proven to be malignant (5 invasive ductal we analyzed the shape and margin of these 80
carcinomas and 2 papillary carcinomas) (Figure lesions, 16 (44%) of 36 lesions composed of
5). Among the 53 sonographic type VI cystic round, oval, or lobular masses with sonograph-
masses, 20 (37.7%) were proven to be benign ically circumscribed margins were proven
(7 fibrocystic changes, 2 abscesses, 8 fibroadeno- malignant (Figure 6). Surgery was performed in
mas, 2 papillomas, and 1 phyllodes tumor), and 32 cases (16 mastectomies and 16 breast con-
33 (62.3%) were proven to be malignant (19 inva- servation surgeries with axillary lymph node
sive ductal carcinomas, 2 ductal carcinomas in dissection).
situ, 4 metaplastic carcinomas, 5 malignant
phyllodes tumors, 1 papillary carcinoma, and 2
mucinous carcinomas) (Table 2). There were 80
Figure 3. Radial sonogram from a 38-year-old woman shows a
cases of cystic masses with solid components, cyst with thin (<0.5-mm) septa, classified as type III (arrow-
composed of types V and VI, and 40 (50%) lesions heads), which otherwise met the criteria for a simple cyst. The
were proven malignant (Table 3). All the lesions cyst disappeared after aspiration, and the pathologic result was
benign cyst contents.

Table 1. Subclassification, Method of Sampling, and

Rates of Malignancy in 175 Cystic Lesions
Rate of
Sonographic Malignancy,
Feature Aspiration CNB Excision n (%)

Type I (n = 23) 17 5 1 0
Type II (n = 15) 10 4 1 0
Type III (n = 22) 14 6 2 0
Type IV (n = 35) 26 7 2 0
Type V (n = 27) 21 1 5 7 (17.5)
Type VI (n = 53) 35 16 2 33 (82.5)
Total (n = 175) 123 39 13 40 (100)
CNB indicates core needle biopsy.

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Benign and Malignant Cystic Lesions of the Breast
Figure 4. Transverse sonogram from a 34-year-old woman with
complicated cysts (type IV) shows well-defined oval masses with
homogeneous internal echoes (arrowheads). Aspiration yielded
2 mL of milky fluid, and subsequent excisional biopsy revealed
acute and chronic nonspecific inflammation.
In 94 cases, follow-up sonography was per-
formed over 45 months, during which time the
cysts underwent no appreciable changes or had
disappeared at the time of follow-up examina-
tion. One patient (1%) of 94 was proven to have a
newly detected mass, BI-RADS category 4, sepa-
rate from the cyst, which was confirmed as inva-
sive ductal carcinoma on follow-up sonography
after the 36-month follow-up.
Figure 5. Transverse sonogram from a 39-year-old woman with
a thick-walled cystic mass (type V) shows a well-circumscribed
oval cystic mass with thick septa (arrowheads). Aspiration yield-
ed bloody fluid with atypical cells, and subsequent core needle
biopsy revealed cystic degeneration of high-nuclear-grade inva-
sive ductal carcinoma.
50
Discussion
Breast cysts are common findings in women
older than 40 years, and most can be dismissed
as benign (ie, BI-RADS category 2). Type I lesions,
composed of simple cysts, do not require inter-
vention if a patient is not symptomatic because
such cysts have no potential malignancy.4–7 If
patients have symptoms such as pain or palpa-
tion owing to a very large cyst, aspiration can be
performed on an elective basis.1
Because type II lesions, composed of clustered
cysts without a solid component, are considered
benign, routine follow-up is usually recommend-
ed. Berg8 stated that clustered microcysts with-
out a solid component are likely to be benign, on
the basis of their study of 79 lesions with follow-
up, which were not proven malignant. These
lesions frequently occur in conjunction with
apocrine metaplasia or fibrocystic changes, and
apocrine metaplasia appears to be the progeni-
tor of cyst formation in which adjacent acini
unfold and fuse because of increased intralumi-
nal pressure from secretions of forming apoc-
rine-lined microcysts.9 It is possible that larger
type III cysts with thin septa represent the con-
tinuum of the spectrum from apocrine metapla-
sia to cysts as the acini fuse. In our study, 15
sonographic clustered cysts revealed cysts or
fibrocystic changes and no malignancy during
follow-up.
Although we defined type IV cysts as complicat-
ed lesions with homogeneous low-level echoes
that otherwise meet the criteria of simple cysts,
with an imperceptible wall and a fluid-debris
level, 21 (60%) of the 35 cases in our series were
proven to be abscesses. When an abscess was
suspected clinically on imaging or on inspection
of the fluid, we performed aspiration for confir-
mation and initiated a course of antibiotics or
surgical drainage. In a series by Venta et al,7 0.3%
of 308 complicated cysts proved to be malignant;
however, these are usually managed with period-
ic follow-up imaging studies because they are
probably benign lesions. Buchberger et al10
found none of 133 such lesions to be malignant,
and Kolb et al11 found none of 126 such lesions to
be malignant in their series with screening
sonography. Symptomatic complicated cysts
should be managed on the basis of clinical symp-
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Chang et al

Table 2. Correlation of Pathologic Outcome and Sonographic Features for 175 Cystic Lesions
Finding Type I Type II Type III Type IV Type V Type VI Total, n (%)

Benign
Cyst 15 2 9 4 3 0 33 (18.9)
Fibrocystic disease 7 13 11 9 3 7 50 (28.6)
Fat necrosis 1 0 1 0 0 0 2 (1.1)
Abscess 0 0 0 21 7 2 30 (17.1)
Mucocelelike tumor 0 0 1 1 2 0 4 (2.3)
Fibroadenoma 0 0 0 0 1 8 9 (5.2)
Papilloma 0 0 0 0 4 2 6 (3.4)
Phyllodes 0 0 0 0 0 1 1 (0.6)
Total, n (%) 23 (100) 15 (100) 22 (100) 35 (100) 20 (74.1) 20 (37.7) 135 (77.2)
Malignant
Infiltrative ductal carcinoma 0 0 0 0 5 19 24 (13.7)
Ductal carcinoma in situ 0 0 0 0 0 2 2 (1.1)
Metaplastic carcinoma 0 0 0 0 0 4 4 (2.3)
Malignant phyllodes 0 0 0 0 0 5 5 (2.9)
Papillary carcinoma 0 0 0 0 2 1 3 (1.7)
Mucinous carcinoma 0 0 0 0 0 2 2 (1.1)
Total, n (%) 0 0 0 0 7 (25.9) 33 (62.3) 40 (22.8)
Total, n (%) 23 (100) 15 (100) 22 (100) 35 (100) 27 (100) 53 (100) 175 (100)

toms and generally warrant aspiration, with such tumors are rare. Liberman et al14 proposed
abscesses, hematomas, fat necrosis, and galacto- that tumors with cystic foci are more common in
celes being included in the differential diagnosis. malignant phyllodes tumors. According to Berg et
Type V lesions, composed of a cystic mass with al,1 malignancies with eccentric cystic foci have
a thick wall, septa, or nodules, should suggest no particularly distinguishing features in low-
possible malignancy, and biopsy should be per- and high-grade invasive ductal carcinoma. In our
formed. Berg et al1 found that 35% of cystic mass- study, there was no difference in the cellular
es with a thick wall or thick septa were malignant, degree of invasive ductal carcinoma according to
with 86% being high-grade invasive ductal carci- the type VI complex solid and cystic masses.
nomas and 33% having circumscribed margins However, complex solid and cystic masses were
on sonography. In the case of type V, core needle proven to be metaplastic carcinomas, malignant
biopsy of the wall/septum or nodule is preferred phyllodes tumors, and mucinous carcinomas,
to aspiration for providing a specific diagnosis which may represent malignant masses with cys-
because the cystic component can be necrosis or tic components. Papillary carcinoma can be seen
acellularity. In our study, among the 27 type V in cystic masses of the breast. The prognosis of
cases, 7 (25.9%) were proven to be malignant, 5 cystic malignant masses is better than for other
(71%) of which were invasive ductal carcinomas
and 2 of which were papillary carcinomas.
Table 3. Sonographic Findings of 80 Cystic Masses
Abscesses, apocrine metaplasia, inflamed or rup-
With Solid Components and Rates of Malignancy
tured cysts or ducts, and hematomas can also
present as thick-walled cysts. Fat necrosis can Cystic Masses With
Margins Solid Components Malignant, n (%)
manifest as a thick-walled cystic lesion or as a
complex cystic and solid mass.1,12 Circumscribed 36 16 (44)
Round 12 6 (50)
In type VI complex solid and cystic masses, Oval 24 7 (29)
eccentric cystic foci can be caused by duct dilata- Lobular 9 3 (33)
tion, acini, or necrosis. Jackson et al13 first Irregular 0 0 (0)
Indistinct 4 2 (50)
described that fibroadenomas rarely have eccen-
Angular 9 6 (67)
tric cystic foci. The consistent feature of a Microlobulated 21 15 (71)
fibroadenoma with the presence of cystic foci may Spiculated 1 1 (100)
suggest a possible phyllodes tumor, although Total 80 40 (50)

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Benign and Malignant Cystic Lesions of the Breast
Figure 6. Transverse sonogram from a 57-year-old woman shows
a well-circumscribed round solid mass with small internal cystic
components, classified as type VI (arrowheads). The pathologic
result was intermediate-nuclear-grade invasive ductal carcinoma.
forms of breast cancer, and when the internal
fluid is aspirated, it usually contains blood.3,15–17
The hypotheses of malignant masses with cystic
components have been followed as several
research studies investigated the chance invasion
of a carcinoma into an area of cystic disease and
the cystic degeneration of a high-grade malignan-
cy.3,17,18 Papillomas or papillary carcinomas can
be seen in cystic masses of the breast. Intracystic
papillary carcinomas account for 0.3% of all
breast cancers.19
Hong et al20 showed that 16 (9%) of 372 masses
described as both oval and circumscribed on
sonography were malignant. In our study, among
the 80 cases of cystic masses with a solid compo-
nent, 40 cases (50%) were proven to be malig-
nant, and 16 (20%) sonographically detected
circumscribed masses of 80 lesions were proven
to be malignant. This relatively high malignancy
rate was likely due to the exclusive inclusion of
symptomatic patients and likely included the
various pathologic types of benign-looking
malignant masses (eg, metaplastic carcinomas,
papillary carcinomas, mucinous carcinomas,
and malignant phyllodes tumors). In our series,
adequate follow-up was achieved in 97 lesions
classified as cystic masses without a solid com-
ponent, and 1 patient was proven to have had
invasive ductal carcinoma on follow-up sonogra-
phy 36 months after examination. However, on
follow-up sonography, this lesion was proven to
be a newly developed 5-mm solid mass separate
from the cyst.
52
This study had several limitations in that the
cases were selected by retrospectively proven
disease and interpretation of static images,
although static images represent a common
method for retrospectively interpreting clinical
breast sonograms, and there were only a few
cases of each of the classified types. Validation of
this approach from multiple centers is needed.
However, it is notable that the differentiation of
cystic masses is estimated by classifying the
sonographic findings of benign versus malignant
masses with pathologic correlation, and patient
care is subsequently recommended according to
the classified types of cystic masses of the breast.
In summary, because the sonographically
detected simple cysts (type I), clustered cysts (type
II), and cysts with thin septa (type III) were all
benign in our study, interventional treatment was
not needed, but annual routine follow-up appears
reasonable for such lesions. Symptomatic com-
plicated cysts (type IV) should be managed by
aspiration cytology or treatment according to
clinical symptoms. Cystic masses with a thick
wall/septa or nodules (type V) and complex
solid and cystic masses (type VI) should undergo
biopsy with pathologic confirmation, even if
these masses have oval and well-circumscribed
margins.
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