Lack of utility in clinical practice of cytologic examination of nonbloody cyst fluid from palpable breast cysts

Cystic breast masses and the ACRIN 6666 experience

Masses due to cystic lesions of the breast are extremely common findings on mammography, ultrasonography, and magnetic resonance imaging. Although many of these lesions can be dismissed as benign simple cysts, requiring intervention only for symptomatic relief, complex cystic and solid masses require biopsy. Perhaps, the most challenging are complicated cysts, that is, cysts with internal debris. When the debris is mobile or a fluid-debris level is seen, complicated cysts can be dismissed as benign findings. As an isolated finding, homogeneous complicated cysts can be classified as probably benign, with intervention only considered with interval development or enlargement, abscess is suspected, or if suspicious features develop. When multiple and bilateral complicated and simple cysts are present (ie, at least three, with at least one in each breast), a benign, BI-RADS 2, assessment is usually appropriate. Clustered microcysts are common benign findings in pre- and perimenopausal women, though short-interval surveillance may be appropriate for many such lesions in post-menopausal women, particularly if the lesion is new or rather small or deep (ie, diagnostic uncertainty).

Electrolytes and trace elements in human breast cyst fluid

Gross cystic breast disease (GCBD) is one of the most common breast diseases, and women with apocrine (type I) cysts are at higher risk of developing breast cancer than women with flattened (type II) cysts. Type I cysts contain fluid with an electrolyte composition similar to that of intracellular fluid (Na/K ratio <3), whereas type II cysts fluid's content resembles that of plasma (Na/K ratio >3). The electrolyte composition of breast cyst fluid (BCF) has been investigated intensively; however, there have been only a few studies in literature reporting the content of trace elements in BCF. The aim of this study was to compare the concentrations of Na, K, Ca, P, Zn, Cu, Fe, and Na/K and trace element ratios in breast cyst fluid in two subgroups of breast cysts. Sixty-three BCF were obtained by needle aspiration from premenopausal women with GCBD diagnosed by clinical, xheromammographic, and cytological studies. After separation of cells for cytological evaluation, the cyst fluid was centrifuged and supernatant stored at -80 degrees C until the analysis. Sodium, potassium, calcium, phosphorus, and iron were measured using Roche Diagnostics commercial kits on Hitachi 747-200 autoanalyzer. Measurements of copper and zinc were performed by flame atomic absorption spectrophotometer on Shimadzu AAS 680. We found statistically significant higher K, lower Na, higher phosphorus concentrations, and lower Na/K ratios in type I cysts when compared with type II cysts' values. Median values of Na/K ratio in type I and in type II were 0.32 and 6.2, respectively. Higher Zn, Cu, and Fe concentrations with respect to median values were noted in type I cysts; higher [Na.Cu/K.Zn], [Na.Cu/K.Fe], and [Na.Zn/K.Fe] ratios were found in type II cysts. A significant negative correlation existed between Na/K and Cu, and a significant positive correlation between Na/K and Fe in type II cysts (r = -0.660, p = 0.007; r = 0.615, p = 0.014, respectively). We can conclude that the trace elements content of BCF, in addition to electrolytes, could be useful in classifying the breast cyst. Future studies in larger series are needed to confirm these data.

Clinicians' knowledge and attitudes about breast symptom management: is there a use for clinical guidelines?

OBJECTIVE

Failure to appropriately manage women with breast symptoms has resulted in delays in breast cancer diagnoses. We examined clinicians' knowledge and attitudes about breast symptoms and pilot tested an intervention aimed at improving these outcomes.

METHODS

We conducted a controlled trial within an office-based primary care setting. Clinicians in the study and control groups completed a baseline survey. The study group received breast symptoms-related guidelines at the point of care; the control group received no intervention. Both groups completed follow-up surveys. Paired t tests were used to compare differences in presurvey and postsurvey responses among clinicians in the two groups.

RESULTS

One hundred one clinicians participated in the baseline survey (response rate 83%), 55 in the study group and 46 in the control group. About 18% and 11% of clinicians in the study and control groups, respectively, reported the use of the breast-related clinical guidelines (p = 0.32). At baseline, clinicians in both groups had variable knowledge of breast symptom management (correct responses per item ranged from 50% to 97%). Although their attitudes were positive, 21% were uncomfortable with their knowledge of breast cancer risk factors, and 27% were uncomfortable with their skills in identifying and 11% in managing a palpable mass. Following the intervention, the use of either guideline was significantly higher in the study group than in the control group (38% vs. 17%, p = 0.032), but there were no statistically significant differences in the clinicians' knowledge or attitudes.

CONCLUSIONS

Clinicians' knowledge of breast symptoms management varied, and some reported discomfort in their level of knowledge and skills. Although our pilot intervention improved the use of clinical guidelines, it had no statistically significant impact on clinicians' knowledge or attitudes.

Human gross cyst breast disease and cystic fluid: bio-molecular, morphological, and clinical studies

For more than one and a half century the cystic disease of the breast has been recognized as the most frequent female benign breast lesion. Although some conundrums and controversies exist about the relation between gross cysts and breast cancer, recent evidence suggests that the multidisciplinary study of gross cystic breast disease (GCBD) may be a powerful tool for predicting the natural history of the multifaceted gross cyst pathology. A lot of papers have been published on breast cyst fluids (BCF) concerning biochemical, hormonal and morphological aspects, demonstrating that the intracystic fluid contains a wide variety of components (such as ions, lipids, proteins, enzymes, growth factors and antigens) and suggesting that their profile provides additional knowledge on both physiopathology and etiologic pathways of human gross cystic breast disease. The aim of this overview is the critical evaluation of all data accumulated in the last thirty years, in order to highlight the utility of biochemical and epidemiological studies to identify gross cysts, if any, at higher breast cancer risk.

Outcomes of sonography-based management of breast cysts

BACKGROUND

Ultrasound is commonly used during diagnosis of breast lesions. Our purpose was to study the role of sonography for risk stratification of malignancy in the diagnosis and management of palpable breast cysts.

METHODS

This was a cohort study of 176 patients with palpable breast cysts. Sonographic findings were correlated with clinical and pathologic outcomes.

RESULTS

Mean cyst size was 2.0 +/- 1.8 cm. Cysts were simple, complex and probably benign, and complex and suspicious for neoplasm in 82.25%, 10.25% and 7.5% of patients, respectively. Thick cyst wall (P = 0.0001), mural tumor (P <0.00001), eccentric mass (P = 0.034), and internal septae (P = 0.031) were predictive of neoplasm. Of cysts >3 cm, 33% were cancerous (P = 0.000027). After 378 days of follow-up, 26 % of cysts had recurred. Recurrence was more frequent in patients with bilateral or multiple cysts (P = 0.004).

CONCLUSIONS

Sonography is useful in risk stratification of malignancy in breast cysts. There is a high risk of recurrence after cyst aspiration.

Image-guided breast biopsy and management of high-risk lesions

Across several series, the sensitivity of sonographically guided 14-gauge core biopsy is 95%, and the repeat biopsy rate averages 11%. Success of stereotactic biopsy requires obtaining larger volumes of tissue when sampling calcifications; use of vacuum-assisted devices results in comparable sensitivities. For MR imaging-guided percutaneous biopsy,success rates of 95% to 99% have been achieved. Independent of guidance method or the amounts of tissue acquired, the following diagnoses on percutaneous biopsy should generally prompt excision: atypical ductal hyperplasia, lobular neoplasia, radial sclerosing lesions, benign and atypical papillary lesions, and possible phyllodes tumor. Mucocele-like lesions may merit excision. Columnar alteration without atypia probably does not require excision, although further study is needed.

Cystic lesions of the breast: sonographic-pathologic correlation

PURPOSE

To understand the pathologic basis for sonographic features of cystic lesions of the breast and determine appropriate assessment and management recommendations for these lesions based on sonographic appearance.

MATERIALS AND METHODS

From a database of 2,072 image-guided procedures performed from July 1995 through September 2001, 150 cystic lesions were identified. Diagnosis was established with fine-needle aspiration (n = 55), 14-gauge core-needle biopsy (n = 81), or both (n = 14). Excision was performed for all malignant (n = 18) and atypical (n = 2) lesions and for 11 benign lesions, which recurred or enlarged at follow-up. Imaging follow-up was available for 92 of 119 benign lesions. Targeted sonography was performed with high-frequency (10-MHz center frequency) transducers. Imaging and histopathologic, cytologic, and/or microbiologic findings were reviewed. Lesions were categorized as simple cysts, complicated cysts (imperceptible wall, acoustic enhancement, low-level echoes), clustered microcysts, cystic masses with a thick (perceptible) wall and/or thick (> or =0.5 mm) septations, intracystic or mixed cystic and solid masses (at least 50% cystic), or predominantly solid masses with eccentric cystic foci.

RESULTS

Of 150 lesions, 16 were simple cysts aspirated for symptomatic relief. Of 38 lesions characterized as complicated cysts and one cyst with thin septations, none proved malignant, nor did any of 16 lesions characterized as clustered microcysts. Of 23 masses with thick indistinct walls or thick septations, seven proved malignant. Of 18 intracystic or mixed cystic and solid masses, four proved malignant. Of 38 predominantly solid masses with eccentric cystic foci, seven proved malignant.

CONCLUSION

Symptomatic complicated cysts generally warrant aspiration. All clustered microcysts were benign, but further study is required. Cystic lesions with thick indistinct walls and/or thick septations (> or =0.5 mm), intracystic masses, and predominantly solid masses with eccentric cystic foci should be examined at biopsy; 18 of 79 of such complex cystic lesions proved malignant in this series.