- Еуромедик, Булевар уметности 29, Београд
What are breast cysts?
Др Милена Стојановић
Прим др Милош Почековац
др Сава Стајић
Breast cysts are one of the most common benign breast diseases. It is estimated that 7-10% of all women will develop a breast cyst during their reproductive life. Some studies have shown the presence of cysts in 27% of cases out of 300 women who underwent mastectomy. According to Hagens, large cysts are those that are large enough to be felt.
Macrocysts
or palpable cysts make up about 20%-25% of cases and can be 2.5-5cm in diameter.
Microcysts
or non-palpable, are subclinical in most cases and can be visualized by mammography, ultrasound or microscopic examination.
Cysts contain various chemical substances, including pigmented products of apocrine secretion, products of lipofuscin, lipoprotein, hemoglobin 5
Cysts usually appear between the ages of 35 and 50 and may disappear after menopause unless hormone replacement therapy is used. Studies have shown that in 78% of women cysts appear between 35-50 years of age, while only 2.3% are under 30. They occur extremely rarely in older women and do not show a tendency to increase. They may be associated with a papillary tumor when the fluid in the cyst is bloody.
While most cysts contain 5 to 10 milliliters of fluid, some cysts can contain more than 75 ml.
Cysts are a common finding in the breasts. It is an epithelialized space filled with liquid. The epithelium usually consists of two layers: an inner (lumen) epithelial layer and an outer layer of myoepithelial cells. They are usually multifocal and bilateral and vary greatly in number and size.
Why does it arise?
The exact mechanism of cyst formation is not clear, but it is assumed that an excess of estrogen over progesterone may play a role in the formation of cysts. During the menstrual cycle, the breast stroma and epithelium undergo a repeated process of involution, and the cyst appears to be a by-product of an abnormality in this process. Cysts originate from terminal ducts of lobular units. If the stroma surrounding the lobular unit involutes too rapidly, the epithelium of the acini remains, and may form microcysts. These are precursors to macrocysts.
Are the cysts painful?
They are usually asymptomatic, painless and a woman discovers them accidentally. However, there are painful or symptomatic cysts. Pain is caused by the stretching of the surrounding tissue or the leakage of fluid into the tissue, which causes a chemical reaction. The pain is usually not related to the menstrual cycle and the size of the cyst does not matter much. However, large and tense cysts may have a harder consistency and indicate a suspicious lesion. In some women, there may be an increase in cysts and pain sensitivity before menstruation, and after the menstrual cycle, they may decrease in size and the discomfort subsides. It is extremely rare that the cyst communicates with the nipple and thus can be emptied.
If a cyst is diagnosed by ultrasound, it is necessary to perform a puncture with aspiration.
How are cysts treated?
If the cyst is palpable and painful, it is necessary to aspire the cyst.
What is cyst aspiration?
With the help of a thick or wide needle and a 10 or 20 milliliter syringe, we aspirate the cyst.
Is anesthesia required?
Anesthesia is not required as the procedure is almost painless.
Can cysts reoccur after aspiration?
Cysts can reoccur, even after aspiration. It is reasonable to perform aspiration again if the fluid in the syringe is not bloody. However, if the cysts continue to reoccur, excision should be performed, i.e. surgery to completely remove the cyst.
Are the contents of the cyst sent for examination (cytology)?
The sample is sent for cytology only if the fluid in the cyst is bloody.
What is a complex cyst?
A complex (complicated or atypical) cyst is an ultrasound diagnosis characterized by anechoic or cystic and anechoic or solid components. They are noted in approximately 5% – 5.5% of all ultrasound-verified cysts. Unlike simple cysts, complex cysts have a solid component or debris. Radiological follow-up, aspiration or core biopsy or excisional biopsy are advised.
Are breast cysts linked to breast cancer?
Many years ago the author Hagensen confirmed that macroscopic cysts are associated with a certain but very small risk of breast cancer.
Bundred et al. showed a 4.4 increase in risk in women who had cyst aspiration greater than the expected risk. The risk is even higher in women with multiple or bilateral cysts. In one series of 352 women with cysts, 14 developed breast cancer during seven years of follow-up.
It can be said that a cyst can be an indicator of increased risk, but it is not a premalignant condition in itself.
Dixon et al. published a study showing an increase in overall risk, regardless of cyst type. The main factor affecting the risk of breast cancer in this study is age, with the highest risk in women who have cysts before the age of 45. It would be reasonable for such women to enter the screening program from the age of 40
The malignancy rate of complex cysts is 0.3%.
Hormonal therapy
Using birth control pills to regulate your menstrual cycle can help reduce the recurrence of cysts. But because of possible serious side effects, birth control pills or other hormone therapy, such as tamoxifen, are usually and only recommended for women with severe symptoms. Dixon et al. demonstrated that intravenous administration of tritiated hormone (dihydroepiandrosterone sulfate) appears in the apocrine cyst fluid within 2 hours, and remains in the cyst for up to 2 years. Danazol, spironolactone and evening primrose oil can prevent this process, which opens the possibility of therapy. Studies have shown a significant reduction (75%) in the number of cysts after giving Danazol, 100 mg three times a day for 3 months. The benefit was even greater at 6 months, i.e. 3 months after stopping therapy. This suggests that this treatment would be beneficial in more severe cases of painful cysts.
Surgical excision is indicated if the cysts fill again after aspiration or if the fluid is bloody.
Alternative methods in case of painful cysts:
- Avoiding caffeine
- Avoiding salt in the premenstrual diet
- Taking evening primrose oil
- Comfortable bras
- Cold or warm compresses
- Non-steroidal anti-inflammatory drugs (eg Ibuprofen)
Caffeine, salt, evening primrose oil work on breast pain, but there is no reliable data that they are related to breast cysts. However, in some patients, the complaints subside.
1. Santen RJ, Mansel R. Benign breast disorders. N Engl J Med. 2005;353(3):275–285.
2. Haagensen CD. Disease of the breast. 3rd ed. Philadelphia, Pa: W. B. Saunders; 1996. 267–83.
3. Donegan WL. Common benign conditions of the breast. In: Donegan WL, Spratt JS, eds. Cancer of the Breast, Fifth Edition. St. Louis, MO: Saunders, 2002:67–110.
4. Frank GA, Danilova NV, Andreeva LU, Nefedova NA. WHO classification of tumors of the breast, 2012.
5. O’Malley FP, Bane AL. The spectrum of apocrine lesions of the breast. Adv Anat Pathol 2004;11:1–9.
6. VorherrH.