Cystic Breast Masses in Young Women
8/1/2015 - Ashley Wright, MD
Mentor: Todd A. Jenkins, MD
Editor: Pamela D. Berens, MD
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 should be performed. Further evaluation is influenced by ultrasound findings. A persistent mass should be biopsied or excised.
Fibroadenomas, are commonly found solid, non-tender masses in young women. They present as firm, mobile, and rubbery masses and may be multiple in 15-20% of cases. Breast imaging possibly followed by biopsy is confirmatory. 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 should be mobile, with discrete borders, and feel fluctuant or even “elastic.” Ultrasound should be performed to 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 cyst is 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 lactational or nonlactational. The incidence of lactational abscesses in breastfeeding women is 0.1%, and up to 3% in the setting of mastitis. Non-lactational 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 other if there are other concerning features. 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.
ACOG Practice Bulletin No 122. Breast Cancer Screening. August 2011, Reaffirmed 2014
ACOG Practice Bulletin No. 164. Diagnosis and Management of Benign Breast Disorders, June 2016
Original approval August 2015; Revised September 2016.
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