Cystic Breast Masses in Young Women
The differential diagnosis of a cystic breast mass in a young woman includes benign cyst, fibrocystic changes, fibroadenoma, breast abscess, galactocele, fat necrosis, and malignancy. Evaluation should include history, exam, and ultrasound if necessary. Examination includes the axilla, supraclavicular area, systematic breast exam, and evaluation for skin retraction. The size, shape, location, consistency, mobility, and delimitation (presence of borders and edges) are important considerations. The most common etiology of a benign cyst is fibrocystic change, occurring in approximately 50% of women. Breast pain from fibrocystic changes can be cyclical or constant, bilateral or unilateral, or even focal. Physical exam reveals diffuse small cystic masses, described by some as “peas on a plate.” History and physical is usually diagnostic. Elimination of caffeine-containing foods may improve symptoms. If a discrete mass is present, ultrasound is the imaging technique of choice for its evaluation. The increased density of the breast tissue in young women makes mammography less accurate and should not be used in young women as an initial test. Further evaluation is influenced by ultrasound findings. A persistent unexplained mass should be biopsied or excised.
Fibroadenomas are commonly found in young women. They present as solid, nontender, firm, mobile, rubbery masses and may be multiple in 15-20% of cases. Breast imaging may assist, but sometimes biopsy is needed to confirm the diagnosis. The mass size, ultrasonographic features, and level of patient concern often determine need for excision.
Simple cysts occur in up to 7% of women. Simple cysts are mobile, with discrete borders, and feel fluctuant or even “elastic.” Ultrasound can differentiate a simple from a complex cyst. If the cyst is simple, repeat breast exam can be performed in 2-4 months and the patient returned to routine screening if the cyst remains stable or resolves. Office aspiration may be warranted if there is severe persistent pain. If the mass is still palpable after aspiration or if it recurs, further evaluation is indicated. Complex cysts may require frequent ultrasonographic follow-up, aspiration, or even removal depending on the complexity or radiological features.
Breast abscesses can be classified as either lactation or non-lactation related. The incidence of lactation abscesses in breastfeeding women is 0.1%, and up to 3% in the setting of mastitis. Non-lactation abscesses have been associated with tattoos, nipple piercings, and after radiation or surgery. On exam, erythema, skin warmth and thickening, and tenderness are characteristic. Puerperal abscesses can be managed with antibiotics and serial ultrasound guided aspiration. Incision and drainage may be necessary for larger abscesses or if conservative management fails.
Fat necrosis occurs in <1% of women, usually as a result of trauma. It can also be secondary to injections or placement of foreign substances, including breast implants. Areas of fat necrosis can become fibrotic and appear immobile and diffuse, similar to malignancy.
Galactoceles are caused by obstruction of milk ducts, often during weaning. On exam, they are soft, cystic, and typically systemic findings are absent. The diagnosis can be made by aspiration revealing a milky substance. No further workup is necessary.
Malignancy is uncommon in young women, but thorough evaluation of a breast mass is warranted. Diagnostic mammography can be performed in women over 30 or if there are other concerning features on ultrasound in younger patients. Breast malignancies can be associated with nipple discharge, skin changes, or new nipple inversion. On exam, a malignancy will often feel hard and immobile with diffuse edges.
National Comprehensive Cancer Network. Breast cancer screening and diagnosis. NCCN Clinical Practice Guidelines in Oncology , Version 1.2019 – May 17, 2019 [after login, Available at: https://www.nccn.org/store/login/login.aspx?ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf
American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 164: Diagnosis and Management of Benign Breast Disorders. Obstet Gynecol. 2016 Jun;127(6):e141-56. doi: 10.1097/AOG.0000000000001482.
Original approval August 2015; Revised September 2016, January 2018, Minor revision July 2019
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