Breast cysts: Clinical manifestations, diagnosis,

and management
Authors:
Christine Laronga, MD, FACS
Sharon Tollin, PhD, ARNP, AOCNP
Blaise Mooney, MD
Section Editor:
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Deputy Editor:
Wenliang Chen, MD, PhD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Aug 2020. | This topic last updated: Aug 13, 2019.

INTRODUCTION A breast cyst is a fluid-filled round or ovoid mass

derived from the terminal duct lobular unit (TDLU) (image 1). Cysts begin as
fluid accumulation in the TDLU because of distension and obstruction of the
efferent ductule [1]. (See "Breast development and morphology", section on
'Lobule formation'.)

Breast cysts, which can present as a solitary mass or multiple masses, usually
prompt women to seek medical attention because of the palpable mass or
associated pain or discomfort. A breast cyst may be first identified on a clinical
or self-breast examination, or as a mammographic density. Breast cysts may
fluctuate in size, number, and magnitude of symptoms.

The clinical features, diagnosis, and management of breast cysts are the
focuses of this topic. Information on evaluation and treatment of solid breast
masses, both benign and cancerous, can be found in other UpToDate topics:

●(See "Clinical manifestations, differential diagnosis, and clinical

evaluation of a palpable breast mass".)
●(See "Diagnostic evaluation of women with suspected breast
cancer".)
●(See "Clinical features, diagnosis, and staging of newly diagnosed
breast cancer".)
●(See "Overview of the treatment of newly diagnosed, non-metastatic
breast cancer".)

EPIDEMIOLOGY Breast cysts are common masses found in

premenopausal, perimenopausal, and postmenopausal women. In a

prospective study of 2809 women at increased risk of breast cancer
development, the American College of Radiology Imaging Network (ACRIN)
6666 protocol found that cysts were identified in 37.5 percent of all women
screened, with the peak incidence between 35 and 50 years of age [2]. During
this three-year screening study, cysts were identified more often in
premenopausal women compared with postmenopausal women (65.1 versus
39.4 percent). Hormone replacement therapy (HRT) was used by 5.4 percent (n
= 73) of postmenopausal women, and 66 percent of HRT users were diagnosed
with cysts.
Symptomatic and asymptomatic small cysts (microcysts) are common in young
premenopausal women [3]. Breast cysts are influenced by hormonal function
and fluctuation. Therefore, they occur during lobular development, menstrual
cyclic changes, and lobular involution in premenopausal and perimenopausal
women [4]. (See "Overview of benign breast disease", section on
'Nonproliferative breast lesions' and "Clinical manifestations, differential
diagnosis, and clinical evaluation of a palpable breast mass", section on
'Benign'.)
The natural history of breast cysts consists of cyclic development and
regression; 69 percent resolve within five years [5].

CLINICAL FEATURES

Patient presentation — A breast cyst can present as a painful or painless,

often solitary, mass. The mass may be large (gross), small (microcysts), or a
cluster of small microcysts. (See "Clinical manifestations, differential diagnosis,
and clinical evaluation of a palpable breast mass", section on 'Presenting
symptoms'.)
Acute enlargement of cysts may cause severe, localized pain of sudden onset.
Microcystic changes of the breast frequently cause pain and/or tenderness prior
to the onset of menses, and sometimes pain persists throughout the menstrual
cycle. (See "Breast pain", section on 'Cyclical breast pain'.)
Physical examination findings — Physical examination alone cannot
definitively distinguish between a benign cyst, benign solid mass, and a
malignancy. A large or small breast cyst can be palpated as a smooth, firm,
discrete, and frequently tender mass. Cysts may present as a cluster of small
masses or an ill-defined mass. The texture is variable, often described as
similar to a grape, water balloon, or even a hard mass. Some, but not all, cysts
have a sharp distinct border and are ballotable. (See "Clinical manifestations,
differential diagnosis, and clinical evaluation of a palpable breast mass", section
on 'Physical examination' and "Clinical manifestations, differential diagnosis,
and clinical evaluation of a palpable breast mass", section on 'Benign'.)
Imaging — Breast cysts can be evaluated by several imaging studies. The
choice of the initial breast imaging modality depends on the woman's age,
which is discussed elsewhere. (See "Diagnostic evaluation of women with
suspected breast cancer".)
Ultrasonography — Ultrasonography is used to differentiate between a mass
that is fluid filled, solid, or contains mixed elements.
Classification — Cysts are classified as simple, complicated, or complex
based upon the sonographic features (see "Diagnostic evaluation of women
with suspected breast cancer", section on 'Breast ultrasound'):
Simple — A simple cyst is well circumscribed with ultrasonic features that
include posterior acoustic enhancement without internal echoes (anechoic),
solid components, or Doppler signal (image 2 and image 3). Simple cysts are,
by definition, benign lesions.
Clustered microcysts and cysts with thin septa are subsets of simple cysts.
Clustered microcysts are a cluster of simple anechoic cysts, each smaller than
2 to 3 mm, without discrete solid components. Cysts with thin septa that are
less than 0.5 mm in thickness are defined as simple cysts.

Complicated — Complicated cysts are defined by ultrasound criteria as

masses with homogenous low-level internal echoes due to echogenic debris,
without solid components, thick walls, or thick septa, and without vascular flow
(image 4).
Complex — Complex cysts are defined by ultrasound criteria as masses with
thick walls and/or septa greater than 0.5 mm, presence of cystic and solid
components, and absence of posterior wall enhancement (image 4) [6]. The
ultrasound appearance of complex cysts can demonstrate anechoic and
echogenic components.
BI-RADS categories — The Breast Imaging Reporting and Data System (BI-
RADS) final assessment categories used for reporting mammographic findings
and recommendations are also applicable to ultrasound examinations [7-10].
Assessments are either incomplete (category 0) or final assessment categories
(categories 1 through 6) (table 1). The BI-RADS assessments are used to guide
clinical decision making and the need for biopsy:
●Simple cysts, clusters of simple microcysts, and most complicated
cysts are BI-RADS 2 (benign), for which tissue sampling is not
warranted. (See 'Simple cyst' below.)
●Occasionally, complicated cysts can be BI-RADS 3 (probably
benign), for which short-interval (six-month) follow-up exam and
imaging are indicated. (See 'Complicated cyst' below.)
●Complex cysts should be BI-RADS 4 or 5 (suspicious or highly
suggestive of malignancy), for which biopsy is required.
(See 'Complex cyst' below.)
Risk of malignancy — There is no increased risk of breast cancer detection in
a mass that fulfills the ultrasound diagnostic criteria of a simple cyst [3,11], and
breast cancer presenting as a complicated cyst is rare (<1 percent) [2,3,11].
However, the risk of malignancy in a complex cyst generally ranges from <1 to
23 percent [3,12-17]. The wide range of malignant findings may be due, in part,
to technical accuracy of ultrasound to differentiate solid from cystic components
of breast masses and the interpretation of the ultrasound findings.
(See 'Subsequent breast cancer risk' below.)
Ultrasonographic features that increase the likelihood of malignancy in the
complex cystic breast mass include thickened cyst wall, thick septations, mixed
cystic/solid components, lobulations, indeterminant classification, and
hyperechogenicity [3,13,16,17]. The presence of two or more abnormal
ultrasonographic criteria was associated with a 10- to 14-fold increase in breast
cancer detected in the lesion [13,16].
Incomplete resolution and/or bloody fluid following ultrasound-guided fine
needle aspiration were also associated with malignant findings in a complex
cyst [14]. (See 'Complex cyst' below.)
Mammography — Mammography depicts a large cyst (image 5) or a cluster of
small cysts (image 6) as a density that has well-defined or partially obscured
borders. Small microcysts typically are not visualized on a mammogram.
(See "Breast imaging for cancer screening: Mammography and
ultrasonography", section on 'The mammographic examination' and "Diagnostic
evaluation of women with suspected breast cancer", section on
'Mammograms'.)
MRI — Magnetic resonance imaging (MRI) depicts a cyst as a round or oval,
sharply defined mass (image 7). A cluster of cysts is similarly depicted (image
8). The typical cyst will appear as a bright, high-signal-intensity T2 fat-
suppressed weighted image. After injection of gadolinium, a cyst appears as
filling defect, sometimes with rim enhancement. If septations are present, they
are nonenhancing [18]. In a study evaluating complex cystic breast lesions with
MRI, rim enhancement was the dominant pattern in benign lesions [19]. By
contrast, malignant lesions were associated with heterogeneous contrast
enhancement, type III kinetic curve, diffusion restriction, and tall choline peak.
Suspicious cystic lesions found incidentally on breast MRI should prompt further
evaluation with breast ultrasound. The indications and findings on MRI of the
breast are reviewed elsewhere. (See "Diagnostic evaluation of women with
suspected breast cancer", section on 'Breast MRI' and "MRI of the breast and
emerging technologies".)

DIAGNOSIS A breast cyst is suspected by either physical finding of a

palpable breast mass or an abnormal imaging finding (most commonly

mammogram). A breast cyst is diagnosed by breast ultrasound. Breast
ultrasound also provides information about whether the breast cyst is simple,
complicated, and complex; such information dictates further management.
(See 'Management' below.)

DIFFERENTIAL DIAGNOSIS The differential diagnosis of a breast

cyst, whether identified on a self or clinical breast examination, or by an imaging

study, includes benign and malignant lesions [20-22]. (See "Clinical
manifestations, differential diagnosis, and clinical evaluation of a palpable
breast mass" and "Diagnostic evaluation of women with suspected breast
cancer".)
●A mass that fulfills the ultrasonographic criteria for a simple cyst is a
simple cyst. A fine needle aspiration (FNA) that identifies nonbloody
fluid and results in complete collapse of the mass is also diagnostic of
a simple cyst. No further diagnostic evaluation is required.
(See 'Simple cyst' below.)
●The differential diagnosis of a complicated or complex cyst includes:
•Abscess – A breast abscess presents with localized, painful
inflammation of the breast associated with fever and malaise,
along with a fluctuant, tender, palpable mass. Although this is
primarily a clinical diagnosis, ultrasound imaging is helpful for
confirmation of the diagnosis and for directed aspiration of the
purulent drainage. (See "Primary breast abscess", section on
'Clinical features and diagnosis'.)
•Hematoma – Hematoma is a collection of partially solidified
blood that results from trauma or a prior surgical procedure of the
 breast. An ultrasound may reveal a complicated cystic lesion that
may require an aspiration for confirmation.
•Fat necrosis – Fat necrosis of the breast is a benign condition
that most commonly occurs as the result of breast trauma or
surgery and generally can be confused with a malignancy on
physical examination. It may contain partially liquified fat on the
ultrasound assessment. Diagnosis can be confirmed by a
diagnostic needle biopsy. (See "Overview of benign breast
disease", section on 'Fat necrosis'.)
•Galactocele – Galactoceles (milk retention cysts) are cystic
collections of fluid, usually caused by an obstructed milk duct.
These present as soft cystic masses on physical exam but are
not tender and are not associated with systemic findings.
Ultrasound may show a complex mass. Diagnosis can be made
on the basis of the clinical history and aspiration, which yields a
milky substance. (See "Common problems of breastfeeding and
weaning".)
•Noninfectious disorder – Noninfectious disorders, including duct
ectasia characterized by distension of subareolar ducts with
fibrosis, benign inflammatory periductal mastitis, and a ruptured
cyst or duct, may present as a complex or complicated cyst on
ultrasound imaging. (See "Nonlactational mastitis in adults",
section on 'Periductal mastitis'.)
•Oil cyst (image 9) – An oil cyst contains a collection of liquified
fat. If there is any question on the ultrasound, an aspiration can
be performed to confirm a diagnosis. (See "Overview of benign
breast disease", section on 'Fat necrosis'.)
•Malignancy – A colloidal breast cancer or a cyst wall cancer may
have a similar appearance to a complicated or complex cyst on
ultrasound assessment, mammogram, and/or magnetic
resonance imaging (MRI). Apocrine papillary carcinoma can
present as a complex cyst with a mural nodule on ultrasound
[23,24]. Diagnosis can be established by a diagnostic needle
biopsy (preferred) or excisional biopsy. (See "Diagnostic
evaluation of women with suspected breast cancer".)

MANAGEMENT Once a breast mass is identified as a cyst by breast

ultrasound, further management depends upon the clinical presentation of the

patient, and the imaging characteristics and Breast Imaging Reporting and Data
System (BI-RADS) classification of the lesion (algorithm 1).

Generally speaking, simple cysts, clusters of simple microcysts, and most

complicated cysts are BI-RADS 2 (benign), which does not warrant tissue
diagnosis. Occasionally, complicated cysts can be BI-RADS 3 and thus should
undergo short-interval repeat physical exam and imaging in six months.
Complex cysts are BI-RADS 4 or 5 and should undergo ultrasound-guided core
needle biopsy (CNB).
Simple cyst — A simple cyst is benign, and no further intervention is necessary
[25-27]. Clustered simple microcysts are also benign, and no further
intervention is required.
We do not excise simple cysts for any reason. Fine needle aspiration (FNA) of a
simple cyst is only performed for signs of infection or inflammation (red skin). In
such cases, FNA must be performed under real-time ultrasonographic guidance
to assure complete collapse of the cyst [28]. If the aspirated fluid is turbid, it
should be sent for culture, but not cytology, as cyst fluid will always contain
atypical cells. Only frankly bloody fluid should be sent for both culture and
cytology. (See "Breast biopsy", section on 'Cyst aspiration'.)
Following FNA of a cyst that completely disappears, no further management is
required if there is concordance between the clinical examination and
ultrasound results [29]. The patient can then resume routine annual screening
[15]. (See "Screening for breast cancer: Strategies and recommendations".)

If the aspirated cyst does not completely collapse, the procedure can be
converted to an ultrasound-guided CNB to obtain a tissue diagnosis.
Alternatively, if the FNA is done by palpation alone or by ultrasound not
performed by a radiologist, best practice would be to stop and get a diagnostic
mammogram and diagnostic ultrasound first, before pursuing a CNB.

Complicated cyst — Most complicated cysts are BI-RADS 2, which does not

require any further intervention. Occasionally, complicated cysts can be BI-
RADS 3. Complicated cysts classified as BI-RADS 3 should undergo repeat
ultrasound imaging and mammography (if the lesion was visualized on
mammography) and clinical examination in six months [11]:
●Worrisome changes (eg, increase in size, development of a solid
component) should be pursued by an image-guided CNB.
(See "Screening for breast cancer: Strategies and
recommendations" and "Breast biopsy".)
●If the complicated cyst is downgraded to BI-RADS 2 on repeat
imaging, the woman should undergo clinical examination and imaging
(ultrasound and mammography) in another six months. As long as the
latest imaging does not classify the lesion as BI-RADS 3 or above, the
patient does not require any further intervention and can return to
routine annual screening.
●If the complicated cyst remains BI-RADS 3 on repeat imaging, repeat
clinical examination and imaging should be continued every six
months.
This option does require patient compliance. One study showed that 36 percent
of patients who were recommended to have short-term follow-up of cystic
lesions did not achieve two years of compliance [30]. For noncompliant patients
or women uncomfortable with follow-up, biopsy should be performed.
A complicated cyst can also be confirmed as a benign breast lesion by
ultrasound-guided FNA that completely collapses the cyst. If the patient wishes
to undergo a biopsy or is high risk for developing future breast cancer (as
defined by one of the validated risk assessment models such as Gail or Tyrer-
Cuzick), ultrasound-guided FNA can be performed as an alternative to repeat
imaging and clinical examination. (See "Genetic testing and management of
individuals at risk of hereditary breast and ovarian cancer syndromes", section
on 'Risk assessment models'.)
If the aspirated cyst does not completely collapse, further imaging (eg,
mammography) and CNB are required.

Complex cyst — A complex cyst identified by ultrasound must be confirmed to

be a benign or malignant lesion by image-guided CNB [17,31,32]. FNA is not
sufficient, because a sample of the solid component or thickened septa needs
to be obtained, not just cyst fluid.
A sonographically guided CNB is a safe and accurate technique for diagnosis of
indeterminate or complex cystic breast lesions with a solid component [33-35].
When performing a CNB of a complex cystic breast lesion, it is essential to
target the solid component with the first needle pass. Typically, a CNB consists
of three to four biopsy samples. However, if the cystic portion is punctured with
the first needle pass, the cystic component may collapse, making the solid
component of the lesion difficult to identify sonographically.
At the completion of all CNBs, a metallic marker clip is deployed into the biopsy
site to mark the area for future follow-up or surgical excision. If a CNB cannot
be performed due to the position of the breast lesion or technical difficulty, a
surgical biopsy with needle localization is indicated. (See "Breast biopsy",
section on 'Biopsy methods'.)
Correlation of imaging and pathologic findings is essential [36]. If the findings on
imaging and CNB pathology are discordant, surgical excision with needle
localization is indicated.
If the findings on imaging and CNB pathology are concordant and benign,
follow-up includes a clinical breast examination and imaging studies (breast
ultrasound and mammography) every 6 to 12 months for one to two years to
document stability [29]. Any changes in the biopsied lesion or growth of the
lesion should lead to rebiopsy or excision [35,37,38]. A study of 156 patients
who had a benign breast biopsy showed that 13 percent required a subsequent
biopsy within two years [38].
Benign histologic findings associated with complex cysts include a wide range
of diagnoses and should be treated appropriately [36,39]. (See "Overview of
benign breast disease".)
In a retrospective study, 150 patients with benign histology after ultrasound-
guided vacuum-assisted biopsy for complex cystic breast lesions (BI-RADS 4)
were evaluated to determine the appropriate follow-up. This subset of patients
was followed at 6, 12, and 24 months with ipsilateral ultrasound and
mammography. Breast MRI was used rarely (n = 4) for lesions initially seen on
MRI. Of the 104 lesions with available follow-up imaging (mean 34.9 months),
no lesions recurred or underwent malignant transformation [40].
Opportunistic ultrasonic breast screening in Japan was utilized to evaluate
10,519 women at five institutions to further evaluate recall criteria [41]. A cystic
pattern was noted in 6512 cases. One of those cases was found to be
malignant one year later, when an intracystic tumor was biopsied and found a
microinvasive cancer (0.5 mm). Ninety cases found an intracystic tumor, with
evaluation criteria including mass size and the depth/width ratio. No cancer was
diagnosed in this subset of patients. Most of the study subjects were <40 years
of age.
 SUBSEQUENT BREAST CANCER RISK The overall risk of a

subsequent breast cancer is not increased for women with a history of simple
breast cysts [39,42,43]. In a retrospective review of 480 subsequent breast
cancer diagnoses among 14,602 women with benign breast biopsies, simple
cysts were not associated with subsequent breast cancer development [42].
For patients with complicated or complex cysts, the risk of a subsequent breast
cancer is related to the findings from the biopsy. As an example, mucocele-like
lesions are cystic breast lesions that are often associated with atypical
hyperplasia. In one study of 102 patients with mucocele-like lesions, 13 patients
developed breast cancer at a median follow-up of 14.8 years [44].
Persistent, rapidly recurring cysts may require close follow-up. Although rare,
one case report documented invasive ductal carcinoma in a simple cystic mass
[45]. An enlarging breast cyst with irregular and hypoechogenic vegetation
growing on the inner wall revealed a primary squamous cell carcinoma on
biopsy [46].
The risk of a subsequent breast cancer developing in women with
nonproliferative, proliferative, or atypical breast lesions is discussed separately.
(See "Overview of benign breast disease" and "Atypia and lobular carcinoma in
situ: High-risk lesions of the breast".)

SOCIETY GUIDELINE LINKS Links to society and government-

sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Evaluation of breast
problems".)

INFORMATION FOR PATIENTS UpToDate offers two types of

patient education materials, "The Basics" and "Beyond the Basics." The Basics
patient education pieces are written in plain language, at the 5 th to 6th grade
reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10 th to 12th grade reading level and are
best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Common breast problems

(The Basics)")
 ●Beyond the Basics topics (see "Patient education: Common breast
problems (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Breast cysts are fluid-filled round or ovoid masses. Breast cysts can
present as symptomatic gross palpable masses or as microcysts,
usually found as an abnormality on an imaging exam. Cysts usually
prompt women to seek medical attention because of a palpable mass
or associated discomfort. (See 'Introduction' above.)
●A breast cyst is suspected by either physical finding of a palpable
breast mass or an abnormal imaging finding (most commonly
mammogram). A breast cyst is diagnosed by breast ultrasound, which
also classifies it as simple, complicated, or complex. The sonographic
appearance helps guide clinical management. (See 'Diagnosis' above
and 'Classification' above.)
●Simple cysts, clustered simple microcysts, and most complicated
cysts are benign (Breast Imaging Reporting and Data System [BI-
RADS] 2), and no intervention is needed. Fine needle aspiration
(FNA) is only performed if the simple cyst is inflamed or infected (ie,
skin erythema). (See 'Simple cyst' above.)
●Complicated cysts are rarely malignant, but those that are BI-RADS
3 should be followed with imaging and examination every six months
for one year to document stability. Cysts that downgrade to BI-RADS
2 at one year do not need further follow-up. Cysts that remain BI-
RADS 3 require further follow-up every six months. Core needle
biopsy (CNB) is indicated if the lesion increases in size or changes in
characteristics on repeat imaging. (See 'Complicated cyst' above.)
●Alternatively, complicated cysts that completely collapse after FNA
are also benign. Patients who wish for biopsy, are high risk, are
noncompliant, or are uncomfortable with follow-up should undergo
FNA under ultrasound guidance. Complicated cysts that fail to
completely collapse after FNA require further imaging (with
mammography) and CNB. (See 'Complicated cyst' above.)
●Complex cysts (BI-RADS 4 or 5) should be biopsied with CNB. If the
findings on imaging and CNB pathology are concordant and benign,
follow-up includes a clinical breast examination and imaging studies
(breast ultrasound and mammography) every 6 to 12 months for one
to two years to document stability. (See 'Complex cyst' above.)
●Surgical excision is indicated for complex cysts that are not
amenable to CNB and when pathology results from a CNB are
discordant, atypical, indeterminate, or reveal a malignancy.
(See 'Complex cyst' above.)
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Topic 799 Version 21.0
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